Location
Pennsylvania | United States
Job description
Imagine360 is currently seeking a Risk Management Nurse to join our team! The Risk Management Nurse utilizes clinical expertise to evaluate medical claims and underwriting files, providing guidance to internal and external stakeholders.
Position Location : 100% Remote
Responsibilities include but are not limited to:
- Review claim notices from third party administrator to identify possible complex or high dollar claims early in the process.
- Work with stop loss claims, third party administrator and other resources to manage such claims.
- Coordinate with nurse case managers to ensure case management is managing costs and providing good medical outcomes.
- Advise claims adjusters on standards of care.
- Use multiple data sources to confirm appropriateness of bills.
- Consult with claims department management and finance to appropriately set reserves and claim projections.
- Review claims detail for new and renewal underwriting opportunities.
- Advise underwriters on claimant prognosis and anticipated future costs.
- Evaluate medical questionnaires.
- Provide timely and thorough follow up with internal and external customers.
- Demonstrate subject matter expertise.
- Explain complex medical situations to technical and non-technical audiences.
- Recognize and alert appropriate parties of trends in medical services.
- Perform self-quality monitoring in order to develop and execute plans to meet established goals.
- Provide ongoing feedback to help optimize quality performance.
- Collaborates with others and cross-departmentally to improve or streamline procedures.
Education and Experience:
- Bachelor's Degree in Nursing or Associate Degree required with extensive clinical experience
- Prior clinical experience required
- Advanced nursing degree preferred
- Experience in emergency, oncology, or med-surg nursing preferred
- Strong knowledge of ICD-10 and medical bill coding preferred
- Prior health insurance experience a plus
- Working knowledge of computers and software including but not limited to Microsoft Office products
Skills and Abilities:
- Demonstrated organizational skills, problem-solving, analytical skills and detail oriented
- Demonstrated ability to remain neutral and maintain confidentiality
- Strong written and oral communication skills
- Demonstrated ability to work independently, prioritize workloads multi-task and manage priorities in order to meet deadlines
What can Imagine360 offer you?
- Multiple Health Plan Options, including a 100% Employer Paid Benefit Options
- 100% Company paid employee premiums for Dental, Vision, STA, & LTD, plus Life Insurance
- Parental Leave Policy
- 20 days PTO to start / 10 Paid Holidays
- Tuition reimbursement
- 401k Company contribution
- Professional development initiatives / continuous learning opportunities
- Opportunities to participate in and support the company's diversity and inclusion initiatives
Want to see our latest job opportunities? Follow us on LinkedIn
Imagine360 is a health plan solution company that combines 50+ years of self-funding healthcare expertise. Over the years, we've helped thousands of employers save billions on healthcare. Our breakthrough total health plan solution is fixing today's one-size-fits-none PPO insurance problems with powerful, customized, member-focused solutions.
Imagine360 is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.
**RECRUITMENT AGENCIES PLEASE NOTE: Imagine360 will only accept applications from agencies/business partners that have been invited to work on a specific role. Candidate Resumes/CV's submitted without permission or directly to Hiring Managers will be considered unsolicited, and no fee will be payable. Thank you for your cooperation**
Job tags
Salary
$85k - $90k
