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Lead Medical Insurance Risk Consultant/Registered Nurse in Marblehead at QBE

Date Posted: 7/10/2018

Job Snapshot

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Job Description

Utilize knowledge and expertise to execute risk assessments, risk control evaluation, Medical Risk Nurse Consultants provide QBE Medical Stop Loss Underwriters, QBE Claims Analysts and external clients clinical assessment of claimants anticipated care needs and potential costs associated with those needs. Additionally, Medical Risk Nurse Consultants work to facilitate appropriate benefit decisions and the use of unique solutions to ensure optimal claims outcomes.

• Foster effective risk decision-making within area of responsibility by completing complex risk assessments on new and renewal business and by consulting with QBE Underwriting, Claims Analysts and External clients as appropriate on high cost claims and implementing effective clinical risk management solutions by determining the need for any specialty resources or contracts
• Facilitate timely and accurate intake, triaging, tracking and documentation of potential/actual claims. Quickly, thoroughly, and correctly assess a potential/actual claim situation, determine need to impact, develop a sound strategy and successfully influence stakeholders to produce a meaningful clinical and/or financial outcome.

Primary Responsibilities 

  • Ensure effective risk management.
  • Perform  the review and assessment of new business and renewal large claims/disclosure to identify known and potential risk
  • Assist underwriters in the evaluation and assessment of clinical and claims data to identify and quantify known and potential risk through the provision of concise, detailed, and accurate reporting of data analysis findings, observations and recommendations to underwriting.
  • Effectively explain complex clinical conditions to a lay person
  • Develop and maintain strong client, TPA and vendor relationships
  • Consult with clients and TPAs on case management issues, alternative levels of care, program development, quality improvement, claim issues, and educational needs
  • Participate in TPA implementation calls
  • Perform timely and accurate tracking and documentation of probable and actual claims along with timely and thorough assessment of a probable/actual claims to determine the need to impact, develop a cost mitigation strategy and work with internal as well as external stakeholders to produce an effective clinical and financial outcome.  
  • Assist with medical necessity determinations and claim audits.
  • Perform, as needed; transplant and other complex/catastrophic care reviews including review of treatment plan for medical necessity/experimental treatment, appropriateness of setting and coordination of any necessary additional review with outside medical expert
  • Consult with internal and external clients on high cost claims and successfully engages effective clinical risk management strategies.
  • Determine need for extra contractual agreements and/or engagement of specialty resources and acts as a liaison until claim is complete
  • Serve as the lead resource for claims and underwriting related to risk management of A&H claims
  • Establish reserve recommendations
  • Build strong relationships with internal (UW’s, Claims, Policy, Managers) and external clients (TPA’s, external CM’s) through individual credibility and applying business acumen to communicate risk factors, resolve complex inquiries and develop recommendations for continuous improvement and alignment with overall A&H risk strategy
  • Utilize a comprehensive approach to risk mitigation within area of responsibility by monitoring regulatory changes to ensure on-going adherence to reporting requirements 
  • Develop a long-term approach to risk mitigation by performing scenario analyses for future risks and communicating with managers to share recommendations for mitigation and loss control
  • Contribute to a positive environment by demonstrating cultural expectations and guiding leaders to reward performance and value “can do” people, accountability, diversity and inclusion, flexibility, continuous improvement, collaboration, creativity and fun 
  • Adopt QBE values in personal work behaviors, decision-making, contributions and interpersonal interactions; manage own career development by soliciting feedback and valuing other perspectives

Required Qualifications

  • Bachelor’s Degree or equivalent combination of education and work experience


  • 5 years relevant experience


  • RN license required

Preferred Qualifications

  • Licenses/Certifications
  • CCM preferred


  • Working knowledge of Microsoft Excel
  • Working knowledge of relevant legal and requlatory requirements (preferred)
  • Working knowledge of insurance policy and contract language (preferred) 


  • Analyze complex risks to ensure organizational competitiveness and satisfaction of established long-range objectives; evaluate causal relationships
  • Utilize effective research and investigative strategies 
  • Possess analytical and problem-solving skills 
  • Analyze and synthesize data to form options and recommendations
  • Communicate outside and across the organization and share information as a positive aid to achieve best practice and objectives
  • Effectively and efficiently present logic, reasoning, and analysis to others
  • Able to set goals and handle multiple tasks, clients, and projects simultaneously; able to appropriately balance priorities, deadlines and deliverables. Able to quickly adapt to change, work under tight deadlines and stressful conditions.
  • Expert negotiating, persuasion, and conflict resolution skills
  • Must have excellent oral, written, and interpersonal communication skills. PC skills to include word processing, spreadsheet, and database applications. Intermediate typing skills.


  • Apply business and financial acumen
  • Iintermediate level or higher analytical and problem-solving skills
  • High attention to detail
  • Ability to work paperlessly
  • Establish a high degree of trust and credibility with others
  • Effectively present thoughts to key stakeholders to influence adoption of innovative recommendations
  • Maintain regular and predictable attendance
  • Ability to work well within a team and actively participate in team projects
  • Build long-term collaborative working relationships with senior managers

Number of Openings:


How to Apply:

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Equal Employment Opportunity:

QBE is an equal opportunity employer and is required to comply with equal employment opportunity legislation in each jurisdiction it operates.

The companies of QBE North America are committed to equal employment opportunities. All qualified applicants will receive consideration for employment without regard to age, disability, marital or parental status, national origin, citizenship, race, color, religion, sex, sexual orientation, or veteran status. All personal information contained in this application will be kept confidential as required by law.