The Health Services Consultant will provide high quality case management and claims management consulting for our reinsurance clients by assisting them with identifying, assessing and managing high cost cases. This new opportunity is to assure cost effective claims management and promote client satisfaction and retention. This professional will join the ROSE program, a highly respected medical and cost management program exclusively for RGA Reinsurance clients. This role will focus on the quota share, and employer stop loss lines of business.
- Previous employer self-insurance, stop loss, or quota share experience is required.
- Ensure cost effective case management consultation services for high cost/frequency cases. Consult with clients on case management issues, alternative levels of care, program development, quality improvement and educational needs.
- Ensure cost effective reinsurance claims management. Consult with clients on high cost claims management strategies. Establish reserves authorize claim payments, assist with audits, determine need for extra contractual agreements, and monitor clients’ claims activity.
- Work with RGA underwriting, account management and claims staff to improve service to customers and manage the customer relationship.
- Under limited supervision, communicate, market, and educate senior and middle management of current and prospective clients and brokers regarding program services available. Present appropriate information to prospective customers in sales presentations.
- Report industry trends and assist with care and cost management strategies to reduce claim costs for clients and RGA.
- Assist in the underwriting process with regard to evaluation of claims experience, future risk, and clients’ case and claims management capabilities.
- Audit/review clients’ case management and claims management practices on a regular basis. Perform Operational Review (in-depth audit and formal report) of clients’ case management programs under supervision of Senior Health Services Consultant.
- Review reinsurance treaty (contract) wording for clarity/administrative interpretation; evaluate clients’ current and future claims trends and provide recommendations to improve contract clarity.
- Assist with planning and hosting the Annual ROSE Conference and bi-monthly teleconferences, including identifying topics and speakers, obtaining CEU credits and determining events.
- Maintain regular and predictable attendance.
- Other duties as assigned.
Job Requirements :
- Bachelor’s Degree in Nursing/related field, with 5-7 years of experience, or Associate or Diploma Degree with 7-10 years of experience.
- 4-6 years case management experience.
- Current Registered Nurse license and/or current CRRN, CIRS, CCM or CRC certification.
- Knowledge and expertise in health care systems and practices.
- Self insured employer market experience (self insured employer, stop loss carrier, managing general underwriter)].
- Ability to be flexible when needed, take initiative, and demonstrate accountability.
- Intermediate oral and written communication skills demonstrating ability to share and impart knowledge.
- Ability to quickly adapt to new methods, work under tight deadlines and stressful conditions.
- Intermediate level of investigative, analytical and problem solving skills
- Intermediate presentation skills
- Ability to set goals and handle multiple tasks, clients, and projects simultaneously; Ability to appropriately balance priorities, deadlines, and deliverables
- Ability to work well within a team environment and participate in department/team projects
- Ability to balance detail with departmental goals/objectives
- Ability to foster customer service as needed
- Ability to translate business needs and problems into viable/accepted solutions
- Expert negotiating, persuasion, and conflict resolution skills
- General business knowledge including marketing, sales, and financial
- Ability to travel 10-20%