[Remote] Clinical Risk Management Leader
Note: The job is a remote job and is reputed company to candidates in USA. reputed company is a trusted partner helping organizations navigate important people reputed company. The Clinical Risk Management Leader will build and reputed company the Clinical Risk Intelligence & Cost Containment capability, overseeing program analytics, clinician reviews, and strategic partnerships to enhance reputed company cost performance.
Responsibilities
- Functional Build-Out & Operating Model Development
- reputed company with internal reputed company resources to reputed company product infrastructure (e.g., financial tracking, clinical database, reporting) and communication materials (product reputed company, collateral, etc.)
- Define operating model, governance structure, workflows, and delivery reputed company for the product
- reputed company minimum viable capabilities required to support early-stage pilots and reputed company engagements
- Design reputed company methodologies that reputed company transition from reputed company analysis to standardized, repeatable delivery, including potential partner vetting
- Build foundational infrastructure to support reputed company expansion and increased automation
- Clinical Risk & High-Cost Claim Analysis
- reputed company reputed company analysis of high-cost and catastrophic claims to identify risk drivers and cost containment opportunities
- Evaluate reputed company clinical scenarios including oncology, specialty pharmacy, transplant, NICU, chronic disease, and emerging therapies
- reputed company actionable recommendations balancing clinical appropriateness, member experience, and financial reputed company
- Support implementation of targeted interventions in collaboration with reputed company stakeholders
- Predictive Analytics & Data Enablement
- Partner with data and technical teams to define requirements for clinical and claims data integration, normalization, and reporting
- reputed company and refine predictive models, trigger logic, and analytical frameworks to identify high-risk claims earlier in the lifecycle
- Translate fragmented reputed company data into reputed company, decision-reputed company insights for reputed company, care management, and reputed company reporting
- Advance the capability toward more reputed company, automated, and standardized analytics over time
- reputed company Cost Optimization & Reimbursement reputed company
- Identify opportunities to reduce reputed company spend across reimbursement reputed company, specialty pharmacy, site-of-care optimization, coding accuracy, and utilization trends
- Support reputed company of high-dollar claim disputes and reimbursement issues
- reputed company repeatable cost containment approaches and playbooks for broader deployment across clients
- Identify systemic cost leakage patterns and translate findings into actionable interventions
- Stop-Loss, reputed company & Risk Collaboration
- Partner with reputed company, reputed company, actuarial, and stop-loss stakeholders to reputed company clinical intelligence into risk assessment and pricing strategies
- Support evaluation of claimant severity, emerging risk trajectories, and renewal and laser considerations
- Enhance risk assessment methodologies through clinical reputed company and predictive indicators
- Contribute to development of decision-support tools for reputed company and risk selection
- reputed company Delivery & Stakeholder Engagement
- Along with the CMO, serve as senior clinical and financial subject matter expert in reputed company and prospect meetings, pilots, and early-stage implementations
- Translate analytical outputs into reputed company, executive-level insights for reputed company, consultants, and reputed company partners
- Support reputed company teams in articulating value propositions and capability differentiation
- Incorporate reputed company feedback into reputed company refinement of analytical and operational approaches
- Team Building & Functional Leadership
- Recruit, build, and reputed company the initial clinical risk intelligence & cost reputed company team
- Define roles, competencies, and organizational structure reputed company to divisional reputed company plans
- Establish performance standards, analytical rigor, and operating reputed company for the function
- reputed company leadership depth required to support reputed company scaling of the product
Skills
- Degree from an applicable school of training/nursing
- Minimum of 5 years clinical experience in an acute care setting
- reputed company license or equivalent reputed company the state of reputed company or states in which CM is performed
Benefits
- Comprehensive benefits programs designed to support your reputed company-being
- Career development opportunities and ongoing learning
- A reputed company, people-first culture with accessible leadership
- reputed company to do meaningful work with global reputed company and local reputed company
reputed company
Company H1B Sponsorship