Clinical Cost Containment, Consultant

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 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.

This position can either be fully remote (if not within commutable distance to the office) or based in our Hamilton Square NJ office which offers a hybrid work schedule with 4 days in the office; and 1 day remote where it makes sense to do so.

#LI-AV1 #LI-Remote

The company is an equal employment opportunity employer.

As a Clinical Cost Containment RNyou will provide consulting services for internal and external clients and their delegated entities. Youll report to our AVP Clinical Health Risk Management. Well trust you to promote a thorough understanding of current and anticipated clinical needs and expected claims costs while facilitating the use of unique solutions to ensure optimal care and claims outcomes. (The CCC RN will not interact directly with patients).

Youll play an integral role in support of Berkley Accident and Healths vision to be recognized as the industry leader in risk management service. CCC RNs assure optimal clinical outcomes obtained at a cost commensurate with the level of medical services rendered while also promoting client satisfaction and retention.

Well count on you to:

• Be responsible for the independent review of TPA trigger reports 50% notice reports BAH claim referrals or similar information identifying potential catastrophic and/or catastrophic diagnoses or cases of concern regarding potential cost savings opportunities. Actively record act upon and follow-up on identified diagnoses/case of concern in attempts to manage clinical risk mitigation/costs.
• Identify and present future or impending diagnosis of concern with ability to develop determine and recommend clinical risk mitigation course of action for both BAH and our Clients.
• When appropriate independently collaborate with internal departments to attempt to obtain updated/additional clinical or financial information from the client (TPA Policyholder Broker).
• Initiate and collaborate with cost containment vendors in support of Policyholder optimal outcomes.
• Serve as subject matter reference for our companys cost containment programs including but not limited to in our interaction with TPAs Claims Sales Underwriters Client Representatives and Brokers.
• Serve as a subject matter reference in analysis of transplant contracts and provide guidance to the TPA/Case Managers in the selection of the best transplant contract for their client.
• Clinical Data Analytics - expertise in appropriate modules of ESL Office (David Young) with ability to data mine /research and resolve DY data creation of data reporting & data outcomes requiring decision making and presentation skills in order to explain and recommend clinical risk mitigation solutions to both internal and external clients. *Willing to consider skilled candidates without ESL Office experience with proven ability to quickly grasp new computer programs.
• Clinical Benchmarking - utilizing BAH/Client data analytics platforms identify and benchmark current clinical areas of opportunities & concerns within Client & Catastrophic layer.
• Responsible for independently understanding the nuances of each line of business and adjusting activities and interventions based on the uniqueness of each market segment.
• Support Cost Containment department through creation of educational clinical risk management material meetings & presentations for both internal (Sales Claims UW Program/CR management etc.) BAH staff as well as our Brokers/Clients.
• Demonstrate a solid work ethic and maintain a positive attitude.
• Other duties may be assigned.

What you need to have:

• Current unrestricted license as a Registered Nurse. Preference BA/BS in Nursing or related field
• 5 years of direct clinical experience in a hospital or acute care setting
• 3 years of Group medical managed care first dollar health insurance stop loss or reinsurance experience.
• Must have a solid understanding of disease management and standard of care
• Ability to set goals and manage multiple tasks clients and projects simultaneously; ability to balance priorities deadlines and deliverables. Ability to quickly adapt to change and work under tight deadlines.
• Must possess solid negotiation skills confidentiality discretion and tact.
• Must have excellent oral written and interpersonal communication skills.
• Demonstrated mathematical skills proficiency with Microsoft Office Suite.
• Knowledge of Medical Coding to include ICD10 CPT and HCPCS coding certification not required.
• Small group presentation skills and ability to professionally represent BAH.
• Intermediate typing skills required.
  Maintain regular and predictable attendance with ability to adapt to cyclical business needs.
• Ability to travel 5 - 10 %.

What makes you stand out:

• AMS Suite of Products experience a plus
• Ability to manage conflict comfortably and effectively while being open minded to change and innovative ideas.
• independently demonstrate solid work ethic and cheerful outlook regarding working relationships with management and staff to further the BAH mission.
• Ability to work professionally and effectively with co-workers clients vendors and others with whom BAH does business.