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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 savings identification, and complex case management. Proficient in understanding medical insurance, treatment plans, and building positive relationships with diverse stakeholders.
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 ChargesReview of Treatment PlansAnalytical ThinkingDecision-Making SkillsKnowledge of Current Medical ConditionsUnderstanding of Organ and Tissue TransplantationOncology KnowledgeCardiac Illness Understanding
Soft Skills
Organizational SkillsAbility to Work with Diverse PeopleSuperior Service OrientationRelationship Building
Certifications & Qualifications
Registered Nurse License
Industry Keywords
Medical Stop Loss InsuranceHealth InsuranceClinical Case ManagementWorkers’ CompensationTransplantsCAR-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
- Use medical knowledge and research capabilities to help individuals understand needed or potential future treatments and associated costs
- Review claims, underwriting prospects, and renewals to recommend appropriate care and treatment settings
Requirements
What you’ll need- Active Registered Nurse license
- 5+ years of clinical nursing experience required
- Prior Medical Stop Loss insurance experience or 3+ years of complex clinical case management experience in medical, workers’ compensation, or another health insurance setting
- 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 work with a diverse range of people
- 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