Stop-loss Cost Containment Nurse (Contractor, Remote)

Hamilton & Archer Health Services, LLC is a leading health care consulting and contracting company. We are seeking a contracted RN to assist with our stop-loss insurance case reviews. Job Summary Hamilton & Archer Health Services, LLC provides clinical and medical review expertise for cost of care related to stop-loss for its insurance clients. This position is responsible for reviewing stop-loss risk cases, assessing potential cost of care, and making recommendations on laser, risk projections, and other stop-loss related activities. Essential Duties and Responsibilities • Review stop-loss cases and make recommendations on potential cost of care, including lasers. • Apply established guidelines when conducting stop-loss case reviews. • Use reporting and risk identification tools on medical and pharmacy claims to assess risk. • Assist clients in evaluating risks in existing and potential stop-loss groups. • Respond to client inquiries and requests for additional information on large claimants. Education and Experience • Required: ASN or BSN in Nursing, licensed in state of residence. • Required: Minimum of 2 years of clinical experience. • Required: Minimum of 2 years of experience in the stop-loss insurance industry, health care delivery system/industry, payer experience, or cost-containment. • Required: Must understand stop-loss spec deductibles, policy year contract types and carve out programs. Knowledge and Skills • Strong understanding of health and prescription costs. • Knowledge of healthcare delivery systems and providers. • Understanding of disease life cycles, disease progression, and expected health outcomes based on standard care management principles. • Preferred: Familiarity with stop-loss reporting tools, such as AMS, and requirements. • Preferred: Experience with risk mitigation, high claimant detection, and claimant engagement/management. • Strong interpersonal skills with demonstrated ability to collaborate across divisions and with external stakeholders. • Proficiency with MS Office (Word, Excel, PowerPoint, MS Project) in a Windows environment. Physical Demands • Ability to work from a HIPAA-compliant home office environment. Job Type: Contract Pay: $39.00 - $50.00 per hour Expected hours: 10 – 40 per week Work Location: Remote Apply tot his job Apply To this Job