Stop Loss Nurse Case Management, Professional - ASO & ALT Product Mgmt
Professional, Stop Loss Nurse Case Management
This position is responsible for identifying and tracking diagnosis, prognosis, and
potential high costs for members triggering stop loss reporting specific to
carrier and group policy requirements. This involves creating, analyzing and reviewing
multiple internal and external (i.e. ASO vendor reports) reports. Communicates with stop loss carriers to correlate medical expense expectations to renewal quotes and member specific deductibles on renewals. Responds to reinsurance carriers regarding questions about plans of care and future potential costs. Interacts regularly with internal departments such as Medical Affairs and Contracting to determine possible referral facilities and research contracted or negotiated rates for
high cost procedures and out of network claims. Refers identified cases that are not enrolled in MVP’s Case Management, Care Advantage or Disease Management to appropriate internal departments. Works closely with ASO Reinsurance Analysts (responsible for monthly updating and claim submission) to meet tight monthly reporting timeframes and ensure all potential claimants are included. Obtains reporting documents for Reinsurance Specialist to submit reinsurance claims. HIPAA compliant communication with marketing staff and/or group representatives may be required to tie Case Management activities to stop loss coverage or plan/policy exclusions. Performs other
duties as assigned.
- Registered Nurse required with BSN preferred; with a minimum of 2 years case
management and/or stop loss experience;
- Some Stop Loss experience required;
- Demonstrated problem-solving skills with excellent verbal and written communication abilities;
- General knowledge and understanding of Claims, (DRG facilities, claim
negotiations) CM & UM Functions, and MVP offered programs to
assist with cost containment measures
- Strong computer skills including working knowledge of Microsoft Office including Excel/Access;
- Proven success with interacting with providers on delicate matters of medical
necessity and service appropriateness;
- Clinical experience in an acute care clinical setting a plus.
MVP Health Care is an Affirmative Action/Equal Opportunity Employer (PDF). We recruit, employ, train, compensate, and promote without regard to race, religion, creed, color, national origin, age, gender, sexual orientation, marital status, disability, genetic information, veteran status, or any other basis, e.g., Pay Transparency (PDF), protected by applicable federal, state or local law. Any person with a disability needing special accommodations to the application process, please contact Human Resources at email@example.com.
- Job Family Medical Management/Clinical
- Pay Type Salary
- Headquarters Office, Schenectady, New York, United States of America