Medical Underwriting Review Nurse
Who We Are: NFP, an Aon company, is a multiple Best Places to Work award winner in Business Insurance. We are an organization of consultative advisors and problem solvers. We help companies and individuals around the globe address their most significant risk, workforce, wealth management and retirement challenges through custom solutions and a people-first approach. To learn more, please visit: East Coast Underwriters is a leading Managing General Underwriter specializing in Medical Stop Loss coverage for self-funded employer groups. ECU values accuracy, responsiveness, and a commitment to exceptional service for its clients. Medical Underwriting Review Nurse Job Description: Provide initial and updated individual medical risk analysis of self-funded and fully insured groups for proposed stop loss new business and renewals. Review a variety of claim reports including shock loss/High-Cost Claimant, spec/50%, trigger, individual paid claim detail, pending, denied, prescription, precertification and case management notes as well as individual medical questionnaires. Research medical conditions and treatment options using a variety of resources to predict potential future treatment plans, ongoing medical care and their probable costs by state and PPO. Analyze the claims, costs, and clinical information to identify high risk individuals and assess financial costs for the upcoming plan years care for claimants who may exceed the stop loss specific and communicate this to Underwriting and Sales. Document the medical review summary with specific analysis of the member’s clinical condition and annual claims projection with financial risk projection. Provide clinical guidance to other team members as needed. Review Restated Plan Documents for gap concerns and Amendments for stop Loss impact. Qualifications: RN designation required. 5 years of clinical experience preferably in acute care setting. Strong medical knowledge and Claims Experience w/ understanding of CPT (current procedural terminology)/ HCPCS and ICD10 codes (International Classification of Diseases), medical terminology, COBRA, HIPPA and Medicare. Strong understanding of operations of third-party administrators (TPAs) and managing general underwriters (MGUs). Knowledge of Stop Loss, Carrier and Reinsurer reporting, plan language, and contractual requirements. Excellent written and verbal communication skills with an emphasis on confidentiality, tact, diplomacy, and ability to work independently yet support team members with clinical and claims guidance. Exceptional organizational, deductive reasoning and analytical skills along with ability to manage multiple tasks simultaneously. What We Offer: We're proud to offer a competitive salary, PTO & paid holidays, 401(k) with match, exclusive discount programs, health & wellness programs, and more. Our PeopleFirst culture focuses on building and nurturing lifelong relationships with our employees because, at the end of the day, we exist to be there for others. The base salary range for this position is $69,000 to $90,000. The base salary offered will be determined by factors including, but not limited to, experience, credentials, education, certifications, skill level required for the position, the scope of the position, and geographic location. Actual base salary offered will be determined on a case-by-case basis. In addition to the base salary, this position may be eligible for performance-based incentives. NFP and You... Better Together! NFP is an inclusive Equal Employment Opportunity employer.