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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 ExperienceClaims Analysis and CodingData 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 EvaluationRisk AssessmentMedical ResearchData Analysis
Soft Skills
Organizational SkillsTime ManagementEffective CommunicationIndependent Work
Tools & Technologies
MS Office Software
Certifications & Qualifications
CCM Certification
Industry Keywords
Healthcare ClaimsCatastrophic ClaimsThird-Party AdministratorsPayer Side ExperienceProvider Side ExperienceTPA ExperienceMGU ExperienceStop Loss Carrier ExperienceIOA ComplianceHIPAA Compliance
About the role
Key responsibilities & impact- Assist underwriters in evaluating clinical and claim data during the disclosure process to identify potential risk
- Serve as a medical resource for Third-Party Administrators and producers in potential 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 identify and engage new business partners that promote healthcare resources and mitigate claims exposure
- Serve as backup for other department medical staff as needed
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 licensure and certifications as indicated
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