RN Senior Clinical Analyst - Remote

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The RN Senior Clinical Analyst is responsible for reviewing large claim notices to identify potential risks, setting up and monitoring claimants in POWER, and notifying relevant stakeholders as risk levels change. The role also involves educating internal and external customers about clinical trends, researching disease states using reputable resources, and assessing opportunities for cost containment. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Review and assess large claim notices for potential risks. (approx. 25%) Set-up potential large dollar claimants in POWER for ongoing risk assessment and allocation of reserves Continue to follow these claimants on a monthly or bi-weekly basis depending on the severity and change in treatment Know when to set these claimants up based on clinical and cost knowledge Complete review of LCNs within 48 business hours of receipt Notify underwriter and claims auditor of potential risk when first notice received and again as risk changes Educate non-medical internal and external customers regarding clinical trends, treatments, possible outcomes Research medical conditions and disease states for appropriate treatment for specific conditions Utilize reputable clinical resources for research as needed such as NCCN, CDC, Predict Dx Assess all claimants for potential cost containment opportunities. (approx. 20%) Collaborate with TPA, case manager, claims auditor, underwriter, vendor to discuss and place appropriate cost containment measures Maintain timely diary follow-up of all claimants open in POWER. (10%) Index all documentation received Co-manage complex medical cases with Transplant/Dialysis coordinator Provide clinical claim file review for claims auditor as needed. (5%) Perform appropriate research for each clinical claim file review request Provide discussion/answer questions for claims auditor as needed Perform experimental/investigational file reviews for Claims Review PYCS to assist claim auditor in setting appropriate reserves based on known or anticipated cost Reviewed all documents indexed into the package for each cost estimator request. (approx. 40% but during busy season-end of August to December approx. 75%) Perform appropriate research for each cost estimator request Identify all actual and potential risks for each cost estimator request Document clinical summary and estimate cost of care for each individual identified as at risk Provide re-review of additional information for updated cost estimates as needed Complete requests for cost estimates on new business within 24 business hours of receipt and on renewal business within 48 business hours of receipt Provide discussion/answer questions for underwriter as needed Complete Hot Claims reports as needed. This is used to track large claims and any cost containment strategies put in place Attend monthly Account Management/Sales calls