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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical evaluation and claims analysis, with a strong focus on risk assessment and compliance with HIPAA standards. Proficient in managing catastrophic claims and collaborating with healthcare partners to mitigate exposure.
Highest-signal resume keywords
Registered Nurse LicensureCCM CertificationAcute Care Clinical ExperienceHealthcare Claims AnalysisData Entry and Analysis
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical ReviewClaims AnalysisRisk AssessmentMedical ResearchData EntryClaims ReportingHealthcare CodingCatastrophic Claims ManagementTime ManagementOrganizational Skills
Soft Skills
Effective CommunicationProfessionalismIndependent WorkCollaborationPrioritization
Tools & Technologies
MS Office Software
Certifications & Qualifications
Registered Nurse LicensureCCM Certification
Industry Keywords
HIPAA ComplianceThird-Party AdministratorsCatastrophic ClaimsAcute CareUtilization ManagementCase ManagementTPAMGUStop Loss Carrier
About the role
Key responsibilities & impact- Assist underwriters in evaluating clinical and claim data during the disclosure process to identify potential risk
- Work with Third-Party Administrators and producers as a medical resource for catastrophic claim management
- Assist Case Managers with high-dollar catastrophic claimants
- Evaluate claims reporting for potential exposure and reserve recommendations
- Conduct clinical review and claims analysis to assess claim trends and possible group resources
- Maintain patient confidentiality in compliance with IOA and HIPAA standards
- Help seek and employ new business partners to promote healthcare resources and mitigate claims exposure
- Serve as backup for other department medical staff as needed
- Maintain licensure and certifications for professional advancement
Requirements
What you’ll need- Registered Nurse licensure preferred
- Bachelor’s degree in nursing or science
- CCM certification preferred
- At least one year of acute care clinical experience required
- UM or CM experience on either the payer or provider side
- Prior TPA, MGU or Stop loss carrier experience highly preferable
- Prior experience analyzing health care claims and coding
- Prior experience working with catastrophic health care claims
- Experience with data entry and analysis of medical reporting
- Ability to provide risk assessment and communicate analysis succinctly in reporting
- Ability to conduct independent medical research as an adjunct to medical underwriting tasks
- Ability to meet tight time frames
- Strong organizational and time management skills
- Ability to work independently in a remote setting
- Ability to work with multiple offices and underwriters and prioritize time frames
- Strong data entry skills
- Proficient with MS Office software
- Ability to communicate effectively and professionally internally and with external clients
- Maintain required licensure and certifications
Benefits
Comp & perks- Competitive compensation and comprehensive benefits
- Year-round social and community events
- Ongoing mentorship and professional development
- Endless opportunities for upward mobility
- Collaborative, results-driven environment