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Senior Clinical Risk Consultant
Pareto CapitalSenior Clinical Risk Consultant providing clinical expertise and risk assessment for high-cost claimants at ParetoHealth. Collaborating closely with underwriting to inform decision-making.
About the role
Key responsibilities & impact- Review medical records, diagnoses, and treatment plans for individuals and groups with high-cost or complex conditions
- Assess severity, prognosis, and likely progression of illnesses or injuries
- Identify potential high-risk cases, including transplant, oncology, neonatal, and chronic conditions
- Develop evidence-based cost projections for ongoing and future treatment
- Evaluate treatment pathways, including standard of care and emerging therapies
- Estimate timing and magnitude of claims exposure for underwriting purposes
- Partner with underwriters to provide clinical insight on risk selection, pricing, and policy terms
- Support new business and renewal underwriting with case-specific analysis
- Assist in determining appropriate laser levels, exclusions, or coverage strategies
- Analyze appropriateness of care, site of service, and utilization patterns
- Identify opportunities for cost containment or alternative treatment strategies
- Monitor large claims and ongoing cases for changes in risk or cost trajectory
- Translate complex clinical information into clear, actionable summaries for non-clinical stakeholders
- Document findings, assumptions, and rationale for cost projections
- Contribute to reporting on high-cost risks and emerging clinical trends
- Stay current on medical advancements, specialty drugs, gene therapies, and high-cost treatments
- Understand healthcare cost drivers and reimbursement trends impacting stop loss risk
Requirements
What you’ll need- Active Registered Nurse (RN) license required
- Bachelor of Science in Nursing (BSN) preferred
- 5+ years of clinical experience (e.g., ICU, oncology, case management, or utilization review)
- Experience in stop loss, health insurance, underwriting support, or large claims review strongly preferred
- Familiarity with high-cost conditions (e.g., transplants, cancer, NICU, specialty pharmacy)
- Strong analytical and critical thinking skills
- Ability to interpret medical records and translate into financial risk insights
- Knowledge of medical cost drivers and treatment protocols
- Excellent written and verbal communication skills
- Detail-oriented with the ability to manage multiple cases simultaneously
- Proficiency in Microsoft Office (Excel, Word, Outlook)
- Experience with underwriting platforms, or clinical review tools preferred
Benefits
Comp & perks- Fully paid medical, dental, and vision benefits.
- Flexible PTO
- 401k company contribution
- Tuition reimbursement
- Professional development allowance
- Transportation allowance and daily parking reimbursement
- Engaging hybrid work environment
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical experiencecost projectionsrisk selectionutilization reviewtreatment protocolsmedical record interpretationcost containment strategiesclaims exposure estimationevidence-based analysishealthcare cost drivers
Soft Skills
analytical skillscritical thinkingcommunication skillsdetail-orientedability to manage multiple casestranslating complex informationcollaborationproblem-solvingreportingstakeholder engagement
Certifications
Registered Nurse (RN) licenseBachelor of Science in Nursing (BSN)