Stop Loss Registered Nurse

BlueCross BlueShield of South Carolina

. Evaluate and manage catastrophic episodes of illness for underwriting and claims .

Posted 10/22/2026full-timeRemote • South Carolina • United StatesSeniorLead💰 $70,715 - $140,212 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates extensive experience in medical management and case management, with a strong focus on catastrophic claims cost and effective communication with underwriters and TPAs. Proficient in analyzing claims data and ensuring optimal care delivery within managed care systems.

Highest-signal resume keywords

Active RN Licensure10 Years Work ExperienceManaged Care KnowledgeCatastrophic Claims Cost ExpertiseCase Management Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical ExperienceMedical Management ExperienceClaims Data AnalysisCost Containment ResearchUnderwriting ConsultationCase Management OversightHMO Reinsurance KnowledgeMedicare ExperienceMedicaid ExperienceStop Loss Carrier Experience

Soft Skills

Excellent Communication SkillsOrganizational SkillsAnalytical ThinkingDecision-Making AbilityCustomer Service Skills

Tools & Technologies

Microsoft OfficeWord Processing Software

Certifications & Qualifications

Associates Degree in Job-Related FieldGraduate of Accredited School of Nursing

Industry Keywords

Managed CareHealth Care Delivery SystemsCatastrophic Episodes of IllnessClaims ManagementCost-Effective Medical Care

About the role

Key responsibilities & impact

Evaluate and manage catastrophic episodes of illness for underwriting and claims
Ensure insured members receive the best medical care in the most cost-effective manner
Facilitate cost estimates for underwriters for new and renewal stop loss business
Consult with underwriters on catastrophic episodes of illness
Provide case management oversight of managed care between the TPA and the company
Review potential claim notices and excess claims to determine reserve settings
Review potential claim notices from TPAs
Research cost containment and intervene with the TPA as necessary
Work Monday-Friday, 40 hours per week, on an 8-hour shift between 6:00am and 6:00pm

Requirements

What you’ll need

Associates in a job-related field
Graduate of Accredited School of Nursing
10 years of work experience: 5 years clinical plus 5 years medical management experience
Active RN licensure in state hired
Working knowledge of word processing software
Excellent verbal and written communication skills
Ability to work independently, prioritize effectively, and make sound decisions
Working knowledge of managed care and various forms of health care delivery systems
Working knowledge of catastrophic claims cost, medical vendors, and case management
Demonstrated customer service, communication, and organizational skills
Analytical or critical thinking skills
Ability to handle confidential or sensitive information with discretion
Microsoft Office
Experience working with a stop loss carrier and providing underwriting and claims with medical cost projects
Significant case managed and managed care experience
Experience with Medicare and/or Medicaid
HMO Reinsurance experience
Previous solutions-based consulting experience to partner effectively with a wide range of diverse clients
Ability to review and analyze large amounts of claims data and clinical information

Benefits

Comp & perks

Subsidized health plans, dental and vision coverage
401k retirement savings plan with company match
Life Insurance
Paid Time Off (PTO)
On-site cafeterias and fitness centers in major locations
Education Assistance
Service Recognition
National discounts to movies, theaters, zoos, theme parks and more
About 25% of travel to visit clients or participate in team meetings or conferences; travel expenses will be reimbursed
Benefits eligibility beginning the first of the month following 28 days of employment