Profile Summary:

Favorably impact Stop Loss risk profile through early identification of potential high-cost patients.

Profile Description:

Serves as a subject matter expert in the evaluation of medical information to clarify diagnoses, evaluate the severity of medical conditions, and estimate the duration of treatment and expected future costs.

• Research clinical conditions and provides analytical review of the medical and/or pharmacy data to formulate the history of events. Gathers and prepares preliminary clinical and medical analysis based on information from historical claims utilization data.

•Provide support to rate development through timely and accurate clinical and medical analysis to ascertain future risks and support the underwriting and risk management decision.

•Works collaboratively with the cost containment team ensure a proper hand off of potent...