AVP, Clinical Health Risk Management

Berkley Accident and Health is a risk management company that designs innovative solutions to address the unique challenges of each client. With our entrepreneurial culture and a strong emphasis on analytics we can help employers better manage their risk. We offer a broad range of products including employer stop loss benefit captives provider stop loss HMO reinsurance and specialty accident. The key to Berkleys success is our nimble approach to risk our ability to quickly understand think through and devise a plan that addresses each clients challenges coupled with the strong backing of a Fortune 500 company. Our parent company W. R. Berkley Corporation is one of the largest and best managed property/casualty insurers in the United States.

The company is an equal employment opportunity employer.

We have an opportunity for an AVP Clinical Health Risk Management to join our Berkley Accident and Health (BAH) team! This position will report to the VP of Claims and assume overall responsibility for the Clinical Risk department by fostering solid working relationships with both internal and external clients via a strong professional network and keeping abreast of new developments affecting case management and health care cost. You will be responsible for assuring medical risk analysis are completed and appropriate action is taken on large claimants for Stop Loss Medical Group Captives and Managed Care.

We are open with location including remote options

We have a welcoming culture valuingour employees we trademarked the phrase Everything Counts Everyone Matters to describe the Berkley commitment to our people and how we do business. We believe that every person in the organization is important and every accomplishment makes a difference in our results. Come join us!

Key functions include but are not limitedto:

• Lead manage hire train and motivate a team of clinical RNs committed to providing exceptional service to clients administrators vendors and internal BAH resources
• Recruit new staff as needed and proactively identify staffing needs as business grows/evolves
• Manage the equitable allocation of work among the clinical nurses ensuring proper coverage during the claims busy season
• Regularly monitor team metrics identifying referral patterns that may trigger a need for training (either with claim adjusters clinical staff or both)
• Host clinical team meetings and foster case review studies to promote consistency in reviews
• Work closely with the Claim Leaders to innovate workflow with respect to how referrals are received by clinical
• Optimize utility of the claims administration platform/system and documenting claim clinical reviews
• Responsible for oversight of departmental clinical research and analytical review explore new tools and models available that could improve predictive modeling capabilities
• Responsible for coaching and developing effective departmental communications regarding claim/financial projections and rationale to both internal/external clients
• Provide oversight of third party vendor review for utilization by our Policyholders and coordination with other operational areas: underwriting and claims within the company
• Lead group trainings and discussions on new and emerging therapies and claim situations
• Responsible for the review completion and presentation of Health Risk Reviews on various Berkley Programs

• Bachelors Degree required with a preference in Nursing or related field
• 7 years of either Clinical Health Risk/Stop Loss/Reinsurance experience progressively responsible clinical management experiencepreferred
• Requires current unrestricted license as a Registered nurse
• Technical proficiency within Stop Loss
• Preferred to have at least two of the following : Advanced Achievement in Transplant Management (AATMC) Certification in Case Management (CCM) Certified Rehabilitation Registered Nurse (CRRN) or Certified Professional in Utilization Management (CPUM) or American Association of Managed Care Nurses (AAMCN)
• Autonomous Nursing leadership experience; ability to work in a self-directed manner and initiating and prioritizing regular work duties and projects; ability to think analytically critically and problem solve with ability to demonstrate decision-making skills and develop strategic plans
• Exposure to multiple and complex Stop Loss clinical issues with demonstrated experience in generating selecting and implementing solutions to resolve those issues
• Detail oriented organized the ability to multi-task and strong time management skills with the ability to meet deadlines and respond to unexpected requests in a prompt manner
• Proven ability to train and motivate employees; develop communicate and implement departmental and individual staff goals; ability and willingness to give candid and meaningful feedback
• Strong presentation skills to professionally represent and present BAH with both small and large groups
• Strong communication skills: written verbal interpersonal customer service
• Solid mathematical skills strong computer skills proficient in PC environment with MS Word Excel and Outlook
• Solid negotiation skills confidentiality discretion and tact being key skills
• Exemplify solid work ethic and positive attitude regarding working relationships with management and staff to further the BAH mission
• Maintain regular and predictable attendance with demonstrated ability to adapt to cyclical business needs
• Ability to travel 5-10%

BAH - AVP Clinical Claims Risk Management