Medical Review Specialist – Stop Loss

Ullico Inc. is actively recruiting a Medical Review Specialist for our Stop Loss Department located in our Silver Spring, MD office.

The Medical Review Specialist will perform the following duties:

• Obtain and review complete claims information, including large claim and trigger diagnosis reports along with case management and clinical narratives notes on current and prospective stop loss clients. Estimate future costs of known ongoing medical conditions for the next policy period. Communicate these cost projection recommendations to underwriting staff in a timely manner.
• Evaluate medical records and other data including the application of individuals applying for life insurance to project mortality risk.
• Review the medical necessity and appropriateness of hospital claims, physician charges, specialty drug costs, usage and provide recommendation, as needed.
• Gather and analyze clinical information and medical records from plan &/or their administrators for cost containment and future cost determination ; Maintain a close working relationship with plan administrators , vendors , third party payers, employers and re-insurers.
• Interpret documents such as medical reference books, patient medical records, charges, summary plan descriptions, stop loss insurance benefits to evaluate liability/compensability and to make recommendations.
• Compose clinical correspondence and communicate effectively with employees, employers (clients}, TPA claims administrators, claims and underwriting staff and executive management regarding current care and alternative treatments.
• Apply clinical knowledge to make determinations on medical necessity. Troubleshoot complex clinical problems and practice independently without supervision of another licensed professional.
• Assess medical needs, care requirements and alternatives ; monitor and follow up with the Plan Administrator , Plan’s case management vendors , etc. regarding the planning, coordination and progress of treatment; evaluate and recommend alternative treatments/facility , as necessary to facilitate quality, cost-effective medical care for high risk individuals, trigger diagnoses and transplant losses.
• Provide cost containment initiatives by managing an inventory of Stop Loss claims (involving large case management, trigger diagnosis or transplant network losses}, securing additional discounts from providers (either directly or through a preferred vendor) , negotiating prices for medical services and supplies, negotiating settlements , developing transplant networks, evaluating losses, working closely with claims examiners on appropriateness of services/charges and educating clients and stop loss team about cost­ effective alternatives.
• Prepare monthly report on all large case management. Communicate daily regarding large cases to the appropriate individuals.
• Perform other job related duties that may be occasionally assigned.

MINIMUM QUALIFICATIONS: The successful candidate will have a Bachelor’s Degree and over 4 years of experience as a health professional with an RN licensure. Working knowledge of HIPAA regulations required. The candidate must have knowledge and hands-on experience with PC, Work, and Excel. He or she must have effective written and communication skills with all levels of personnel, as well as, customer service skills and the ability to multi-task.

For over 90 years, Ullico, the only labor-owned insurance and investment company, has been a proud partner of the labor movement, keeping union families safe and secure. From insurance products that protect union members, leaders and employers, to investments in building projects that have created thousands of union jobs, our customers continue to trust us with protecting their families, employees, businesses and investments. For additional information, visit www.ullico.com.

We offer a competitive starting salary and an outstanding benefits package including health/dental/vision, 401(k) and pension plan. For immediate consideration please forward your cover letter and resume, including salary history to: HRDRESUME@ullico.com (please include position title in the subject line). Fax 202/962/8856. Ullico is an Equal Opportunity Employer.

Ullico participates in E-Verify.