717-533-4470

Open

Full Time, Employee



Medical Management Nurse – LPN

This will be a new position related to performing Stop Loss reviews performing clinical and risk management support to Capital’s underwriting and stop loss area for new/prospective business and renewal business quoting for the medical and stop loss products. Activities include reviewing high cost claimants (inpatient and outpatient), writing clinical summaries, estimating future costs based on clinical experience.

  • Position is for a Medical Management nurse in the Medical Claims Review Department to review medical necessity requests.
  • The nurse will also review and analyze high claimant reporting packages and external carrier reporting packages.
  • Ongoing clinical review of high dollar claimants (medical and Rx claims) utilizing reports such as 50% threshold and breach reports.
  • Development of case summaries including projected claim costs over the next 12 months.
  • Participate in meetings with underwriting team as appropriate to support business needs.
  • Provide support for external presentations and presents clinical data as needed to support business needs.
  • Review of stop loss claim submission to identify primary diagnosis, determine if claim detail is consistent with diagnosis, determine if additional information or review is necessary for questionable diagnosis or services rendered.

 

Qualifications/Software Knowledge:

  • Licensed Practical Nurse
  • 5+ years clinical experience
  • Coding Experience required
  • Prior experience in healthcare insurance industry a plus
  • Proficient in MS word, Excel
  • Proficient typing skills
  • Excellent communication skills

For more information regarding this opportunity, please send us your resume and an SGC representative will be in touch.



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