Clinical Consultant - Medical Underwriting

Skyward Specialty is a property and casualty insurance holding company formed in 2007. Based in Houston, Texas, and with staff throughout the country, Skyward Specialty provides admitted and non-admitted solutions to retail and wholesale distributors, managing general agents and captive markets. We have built highly respected businesses in specialty lines including management liability, professional liability, medical stop loss, surety, E&S property and liability, and large commercial property, as well as multi-line solutions for the energy, trucking, and construction industries.

At Skyward Specialty, we approach this business differently. In fact, we’re different from most others in our industry in just about every way. We have the spirit of a start-up with the security of over $1.7 billion in Written Premium. We put immense brain power and energy into finding greater insights to uncover better opportunities for our clients, partners, and people. We think at a higher level, so they can succeed at a higher level.

We are committed to a Diverse Workforce

Skyward Specialty is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, nativity, neurodiversity, genetics, disability, age, or veteran status. For more information about us please visit www.skywardinsurance.com

Job Summary:

The Clinical Consultant will be responsible for daily oversight and management of clinical risk within the employer stop loss business. This role involves working closely with underwriting, claims, internal leadership as well as TPA’s, clients and producers sharing clinical expertise, recommending cost-containment measures as well as assisting with evaluating and processing complex claims.  This role is instrumental in notifying internal stakeholders

Key Responsibilities:

• Establish and maintain relationships with Policy holders, TPA’s and Producers as clinical point of contact.  Obtain clinical and financial information as needed to ensure proper adjudication of claims according to the stop-loss agreement.  Educate parties on risk and how to effectively manage it, as well as recommending cost-containment strategies and vendors, as appropriate.
• Interpret contracts and policies including stop-loss agreements, cost-containment agreements, and transplant contracts, etc.
• Review 50% Notification, at least monthly; outreach policy holder, TPA or producer to obtain additional clinical and financial information.  Identify cases of concern, projecting costs and recommending reserves.  Notify internal stakeholders of high-cost claimants. Including clinical justification.
• Regular review and adjustment of reserves based on receipt of additional clinical and financial information, minimally monthly.
• Conduct clinical educational sessions with internal and external stakeholders as needed to further Sky ward’s market position on being a knowledgeable leader with risk.
• Document in ESL system, following established protocols per the Standard Operating Procedures (SOP’s).
• Perform reviews of clinical, claims and financial information as a part of the UW process (disclosure, new or renewal) projecting costs and recommending lasers. Collaborate with UW, Claims and Policyholder as needed to ensure a smooth and integrated client experience.
• Analyze medical records, treatment plans and financial information to ensure appropriateness of treatment, medical necessity, experimental/investigational, and reasonable/customary both clinically and financially.
• Support VP with the development of Skyward’s Standard Operating Procedures (SOP’s) and marketing material content.
• Clinically support Policyholder and vendor meetings as needed.
• Participate in continuous learning and self-development of risk, market trends, mitigation strategies, as well as clinical and financial emerging trends utilizing formal and informal channels.

• 5+ years of clinical experience to include case management, ICU, NICU, Oncology or transplant related experience preferred
• RN license required
• CCM preferred
• Bachelor's degree preferred
• Stop loss and reinsurance experience preferred
• Excellent written and oral communication skills
• Ability to multi-task and prioritize
• Team oriented yet able to work independently
• Ability to build and maintain strong professional relationships
• Proficiency with Excel, Word and spreadsheet analysis
• Strong customer focus, both internal and external\

Compensation & Benefits

The applicable base salary for this opportunity is $90,000 - $130000.  The base pay offered will be determined by factors such as experience, skills, training, location, certifications, education, and any applicable minimum wage requirements.  In addition to the base salary, this opportunity may be eligible for performance-based incentives.

We are excited to offer a competitive total rewards package which includes health and welfare benefits, tuition and professional certification assistance, 401k savings, elective participation in the Employee Stock Purchase Program, paid time off, paid holidays, and child bonding leave, as well as other employee assistance programs.

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