Job Description
Job Summary: Lockton is currently seeking a Custom Clinical Specialist within its Advanced Medical Advisory Practice. The objective of this role is to provide complex claims management with the focus of identifying opportunities and working collaboratively with key stakeholders to reduce the severity of catastrophic claims while improving the quality of care for client health plan members. Clients include large commercial health plans and employers requiring a high touch approach with both reviews and client interaction and engagement.
• Review client’s medical and pharmacy claims data to identify opportunities to improve quality of care, enhance health outcomes, improve member experience and/or reduce cost of care.
• Review escalated and complex cases to identify and monitor opportunities.
• Actively participate in client strategy meetings to discuss high-cost member outlook and potential intervention opportunities.
• Interpret and articulate clinical findings to tell the story of the member’s health care journey and the impact of interventions recommended to the client.
• Explain disease states and associated costs to internal teams and external clients.
• Validate cost-of-care estimates used in the risk assessment of stop loss underwriting.
• Consult and advise on medical/clinical care approaches.
• Serve as a subject matter expert regarding medical necessity issues, current standards of care and analysis for reimbursement of submitted stop loss claims.
• Serve in a leadership role for assigned clients.
• Lead client and stakeholder calls to review case level details.
• Ensure productivity meets practice needs.
• Execute opportunities agreed upon with clients and continue to follow up until completion.
Requirements: • Licensure as a RN or Bachelor's in Healthcare Management or related field.
• CCM, CPC or other certification or designation is a plus.
• 5+ years of clinical/risk management experience.
• 2+ years of claims and/or utilization review experience.
• Experience in health care costs and benchmarking.
• Working knowledge or experience in quality and care management.
• Knowledge of health insurance processes.
• Understanding of claim coding and processing, including CPT and ICD-10 coding.
• Ability to translate complex clinical topics and subjects to a non-clinical audience.
• Effective communication, presentation and negotiation skills.
• Demonstrated advanced analytical and problem-solving skills.
• Ability to work collaboratively with all levels of an organization in a dynamic and fast-paced environment.
• Proven record of accomplishment for managing multiple competing priorities.
• Strong organizational and time management skills with ability to handle multiple tasks simultaneously.
• Working knowledge of Microsoft products (Word, Outlook, PowerPoint, Excel).
• Ability to travel on an as needed basis.
• Legal right to work in the United States.
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