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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical nursing with a focus on medical claims review, cost assessment, and risk management. Proficient in understanding complex medical treatment plans and providing educational support to diverse audiences.
Highest-signal resume keywords
Active Registered Nurse License5+ Years Clinical Nursing ExperienceMedical Stop Loss Insurance ExperienceComplex Clinical Case ManagementUnderstanding of Medical Insurance
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical Claims ReviewCost Savings IdentificationNegotiation of Medical ChargesAnalysis of Treatment PlansUnderstanding of Organ TransplantationKnowledge of Oncology TreatmentsKnowledge of Cardiac IllnessDecision-Making SkillsAnalytical ThinkingOrganizational Skills
Soft Skills
Ability to Work with Diverse PeopleSuperior Service OrientationRelationship Building
Certifications & Qualifications
Registered Nurse License
Industry Keywords
Medical Stop Loss InsuranceHealth InsuranceWorkers’ CompensationClinical Case ManagementTransplantsCAR-T TherapiesGene Therapies
About the role
Key responsibilities & impact- Coordinate with senior management, claims specialists, underwriting, sales team, and TPAs to review medical claims for appropriateness
- Identify cost savings opportunities and assess potential risk
- Investigate and negotiate medical and prescription charges
- Suggest care alternatives and identify billing errors
- Review complex medical treatment plans for appropriateness and coverage, including transplants, CAR-T therapies, and gene therapies
- Create and facilitate educational presentations for internal and external audiences
- Review claims, underwriting prospects, and renewals to recommend appropriate care, cost, and setting
- Help individuals understand needed or potential future medical treatments and their costs
Requirements
What you’ll need- Active Registered Nurse license
- 5+ years of clinical nursing experience
- Prior Medical Stop Loss insurance experience or 3+ years of complex clinical case management experience in medical, workers’ compensation, or another health insurance setting
- Ability to work with a diverse range of people
- Understanding of medical insurance
- Independent analytical thinking, organizational, and decision-making skills
- Excellent working knowledge of current medical conditions and treatment plans
- Understanding of organ and tissue transplantation, oncology, cardiac or other critical illness
- Ability to provide superior service and build and maintain positive relationships
Benefits
Comp & perks- Discretionary annual incentive award based on individual performance and overall business performance
- Generous vacation and sick time
- Paid family, parental and adoption leave
- Medical coverage
- Company-paid life and AD&D insurance
- Disability programs
- Partially paid sabbatical program
- 401(k) employer match
- Stock purchase options
- Employer-funded retirement account
- Flexible, inclusive and collaborative work environment
- Career growth support