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.

• Researches 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 potential

high cost patients. Prepares clinic...