Clinical Account Consultant
Health Care Service Corporation
Salary
💰 $97,500 - $162,500 per year
Job Level
SeniorLead
About the role
- Use your knowledge to better understand the care journeys of complex members, often piecing together a puzzle from various sources of information.
- Evaluate complex member cases to develop accurate cost projections, drawing from claims data, prior authorizations, industry trends, and other sources.
- Provide clinical insights into likely treatment pathways (e.g., oncology, transplant, critical care, specialty drugs) to anticipate costs and inform underwriting decisions.
- Collaborate with underwriting, stop-loss, clinical services, and actuarial teams to ensure projections align with both financial and clinical realities.
- Identify early intervention opportunities (e.g., site-of-care optimization, alternative medications, post-acute care settings) to mitigate future high costs.
- Interpret plan language and coverage details to anticipate financial impact and reduce avoidable member and group abrasion.
- Synthesize findings into clear summaries and reporting for underwriters, actuaries, and leadership.
- Work cross-functionally to improve processes for high-cost claimant identification, case flagging, and cost containment.
- Combine your experience of evidenced based practice with being innovative to drive new solutions for the best member experience.
- Create effective relationships, listen, communicate and be a helpful team member across the organization.
Requirements
- Bachelor’s degree in nursing
- Active RN license in the state hired
- Experienced with evaluation of risk for costs and health outcomes
- 10+ years of experience in clinical care, managed care, underwriting, or stop-loss risk evaluation
- Strong expertise in catastrophic claims cost drivers (e.g., oncology, transplants, neonatal/critical care, specialty pharmacy)
- Proven ability to analyze risk and forecast costs using both clinical and financial data
- Exceptional verbal and written communication skills
- Demonstrated customer service, communication, and organizational skills
- Ability to work independently, prioritize effectively, and make sound decisions
- (Extra credit) Previous experience at a high growth company
- (Extra credit) Familiarity with actuarial models and tools or cost modeling platforms
- (Extra credit) Previous experiences with working both Underwriting and Stop Loss teams
