Job Description

Company Details

Berkley Accident and Health is a member company of W. R. Berkley Corporation, a Fortune 500 company. Berkley Accident and Health provides an innovative portfolio of accident and health insurance products. It offers four categories of products: Employer Stop Loss, Group Captives, Managed Care (including HMO Reinsurance and Provider Excess), and Specialty Accident.

Berkley Accident and Healths two primary office locations are Marlborough, MA and Hamilton Square, NJ, and the company underwrites Stop Loss coverage through Berkley Life and Health Insurance Company, rated A+ (Superior) by A.M. Best. For more information, please visit BerkleyAH.com .

Responsibilities

The Clinical Underwriting Nurse I or II will perform individual medical risk analysis on large claimants for proposed ESL, EmCap, and Managed Care new business and renewal business. Review policyholder data to identify claimants with catastrophic care needs and assess medical & claims information available to calculate potential risk.

* Assess medical risk for each identified claimant utilizing all available information and applying appropriate guidelines to meet the financial risk management goals of the company.
* Reviews detailed large claim reports from a variety of sources including trigger reports, detailed individual claim reports, pending and denied reports, case management reports, and utilization reports.
* Analyzes medical procedures codes, medication J codes, and prescription drug reports to assist in predicting the future claim costs.
* Researches rare/complicated medical conditions/treatment options using resources including the internet, nursing, clinical resource tools by state/network.
* Presents and documents a clear medical review summary with an analysis of the current clinical conditions and a future annual claim projection to the underwriter.
* Stays informed of current medical and drug trends and shares information with team members.
* Planning Develop work plans, establish timelines, and set goals for assigned work.
* Make necessary referrals to Clinical Cost Containment Services and partner with that team as needed to ensure financial risk management and clinical cost containment effective support based on their clinical needs.

Qualifications

* Underwriting Nurse I would have an Associate or Bachelors Degree in Nursing or related clinical field, three years direct clinical experience, preferably in an acute care or manage care and 2 years experience in medical underwriting or medical risk management or equivalent combination of education and experience.
* Underwriting Nurse II would have a Bachelors Degree in Nursing or related clinical field, three years direct clinical experience, preferably in an acute care and 4 years experience in medical underwriting or medical risk management, clinical coding or AHIP certification, or equivalent combination of education and experience.
* Registered Nurse (RN).
* Exceptional organizational and analytical skills; demonstrated ability to manage multiple tasks simultaneously.
* Demonstrated analytical skills and ability to exercise sound judgment, initiative and discretion in a mature and sensitive manner.
* Computer skills including experience using Microsoft Office (Word, Excel, Outlook) or comparable software and ability to learn and use complex systems.
* Demonstrated ability to establish effective working relationships with coworkers and customers.
* Ability to work independently within minimal direction and supervision.
* Knowledge of ICD 10 coding and medical terminology.
* Knowledge of state and federal regulations related to underwriting.
* Strong verbal, written, interpersonal communication and customer service skills.
* Ability to interpret policies and procedures and communicate complex clinical topics effectively.