The Claims Focused Research Nurse will report to the SVP of Claims and interact primarily with claims staff, administrators, medical facilities and vendors. The CFRN will provide support to claims on difficult cases and project costs for treatment for that policy year.
Data review, clinical assessment, medical status research and clinical experience
Produce a quarterly department newsletter for A&H Division
Create and maintain an information library/database for use by non-medical staff, generated from research as it pertains to diseases, treatment and drugs impacting cost/pricing
Operate as clinical contact for vendors/cost containment
Review and clear system generated claims referrals
Demonstrates ability to effectively and efficiently research current usual and customary billing for procedures, diagnostics, inpatient stays, etc.
Using available information, identify diagnosis, treatment and medications that can generate high dollar claims. (impact cost by applying consistent risk analysis standards, and then provides recommendations.)
Develop and implement a pre and post-payment review system focused on events that generate high dollar claims.
Knowledge and expertise in health care systems and practices
Extensive knowledge of medical terminology and disease process
Knowledge of ICD-10, and CPT/HCPCS coding (work within stop loss, healthcare insurance/managed care setting strongly preferred)
Working knowledge of stop loss insurance process, including underwriting, claims and cost management functions
Experience in medical (disease and drug) research
Experience using software applications such as Microsoft Office Word, Excel and PowerPoint (above average ability using Microsoft Excel)
Keen eye for details and accuracy when reviewing and evaluating documents associated with clinical experience, coverage eligibility and claims
Exceptional written, verbal and interpersonal communication skills
Knowledge of administrative procedures
Highly organized and efficient
Strong organizational and analytical skills
Internal Number: 081519
About Houston Inernational Insurance Group - Accident & Health
With our team of experienced stop loss professionals, averaging more than 20 years in the business, and owned by Houston International Insurance Group (HIIG), HIIG Accident & Health is a direct writer of Medical Stop Loss for employer groups and Taft-Hartley trusts that self-fund their medical benefits.HIIG A&H is a leading provider of Medical Stop Loss, bringing creative stop loss solutions to Third Party Administrators, Brokers and Consultants, through a variety of flexible stop loss options. We provide stop loss insurance for catastrophic claims to protect self-funded plans.HIIG A&H writes stop loss on Great Midwest Insurance Company (GMIC) paper, a wholly owned subsidiary of Houston International Insurance Group, and rated “A-” by A.M. Best. HIIG is an international specialty insurance group headquartered in Houston, Texas and founded by Stephen L. Way.