Clinical Stop Loss Nurse

Blue Cross Blue Shield of IL, MT, NM, OK & TX – Mesa, AZ

This is a work-from-home position with flexibility to come into the office, or travel to occasional off-site meetings, as needed.

Job Purpose:
This position is responsible for the review of case management notes, large claims reports and shock reporting for individuals and groups seeking Stop Loss Insurance quotes and renewals. The position works closely with internal claim, clinical and case management teams to develop ongoing care and cost projections. The projections are then communicated to underwriting to help evaluate potential risk and associated costs.

Required Job Qualifications:
  • Bachelor s degree in nursing (or equivalent combination of education and experience totaling 4 years) with current state licensure plus at least 3-5 years of clinical experience.
  • 2-4 years experience with Stop Loss products and clinical programs
  • Strong analytical and problem solving skills
  • Excellent organizational and time management skills, able to work independently with little supervision while handling numerous projects at once
  • Excellent written/verbal communication skills, especially the ability to communicate effectively with underwriting staff
  • Ability to complete cost projections on new and renewal business within 24-48 hours of receipt
  • Documentation with clinical summary and estimated cost of care for each individual identified as at risk
  • Must have a track record of producing work that is highly accurate, demonstrates attention to detail, and reflects well on the organization
  • Computer proficiency, specifically strong typing skills and Internet research skills, must have a clear understanding of Microsoft Word, Microsoft Office and Excel preferred

  • Preferred Job Qualifications:
  • Clinical claims review and claims auditing experience
  • Experience in managing complex or catastrophic health cases
  • Specialty clinical experience in intensive care medicine, orthopedic, NICU/pediatric, oncology, diabetic member management, obstetric (low to high risk maternity management)
  • Working toward or completion of CCM/CCP/CDE/MCG certification or Advanced degree
  • Knowledge of Milliman Guidelines or similar clinical guidelines
  • Knowledge of medical management policies and procedures
  • Ability to travel - 10%
  • HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants. We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.

    Requirements:Expertise Nursing
    Job Type Full-Time Regular
    Location MN - Bloomington, TX - Marshall, IL - Chicago, NM - Los Alamos, TX - College Station, MA - North Andover, CO - Greeley, TX - Tyler, TX - Houston, IL - Aurora, NM - Ruidoso, IL - Danville, NM - Carlsbad, TX - Beaumont, GA - Gainesville, NM - Gallup, TX - Lufkin, OK - Oklahoma City, MT - Billings, TX - Lubbock, IL - Peoria, TX - Abilene, MI - Southfield, MA - Braintree, TX - Richardson, IL - Champaign, MT - Helena, TX - Temple, IL - Quincy, DC - Washington, IL - Downers Grove, TX - Corpus Christi, OK - Tulsa, PA - Pittsburgh, MO - St. Louis, IN - Indianapolis, NM - Alamogordo, MN - Worthington, TX - Laredo, TX - Fort Worth, MT - Great Falls, IL - Bloomington, NM - Clovis, NM - Santa Fe, TX - San Antonio, MI - Royal Oak, IL - Rockford, TX - Waco, IL - Mt. Vernon, TX - Dallas, GA - Atlanta, NM - Taos, TX - Amarillo, MN - Minneapolis, MN - Eden Prairie, TX - El Paso, CO - Greenwood Village, IL - Springfield, NM - Roswell, MT - Missoula, NM - Albuquerque, NM - Las Cruces, NM - Hobbs, IL - Naperville, IL - Waukegan, GA - Athens, TX - Austin, AZ - Mesa, TX - Nacogdoches, TX - Midland, TX - Wichita Falls

    HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants.

    If you are an individual with a disability or a disabled veteran and need an accommodation or assistance in either using the Careers website or completing the application process, you can email us here to request reasonable accommodations.

    Please note that only requests for accommodations in the application process will be returned. All applications, including resumes, must be submitted through HCSC s Career website on-line application process. If you have general questions regarding the status of an existing application, navigate to my account and click on View your job submissions .

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