Clinical Risk Analyst-1

Tokio Marine HCC (TMHCC) brings 50 years of service to the specialty insurance industry, today offering over 100 products to commercial customers in 180 countries around the world.  Organic growth and over 60 successful acquisitions have grown our 2022 Gross Written Premium (GWP) to $5 Billion.  Our workforce has grown to 4,300 worldwide … big, but not so big that you cannot make a difference.  Our Good Company values, including integrity, empowerment, and commitment to customer service, and a culture of innovation, communication, and collaboration make TMHCC a great place to work. 

TMHCC Stop Loss, a $2 Billion division within TMHCC, leads the way in providing medical stop loss insurance sold to employers. Medical Stop Loss provides an added layer of insurance protection to employers who choose to self-fund their health benefit plans. Self-funding can incur risks from catastrophic claims, and Medical Stop Loss insurance from Tokio Marine HCC is designed to protect employers from that risk. 

This role is remote

Position Summary:

Clinical Claims & Reserve Analyst is responsible for the clinical evaluation of complex and high-dollar claims and the accurate establishment, monitoring, and adjustment of reserves. This role combines clinical expertise with strong analytical and operational skills to ensure reserves are set in alignment with medical findings, underwriting requirements, and company policies. The position requires collaboration with claims, underwriting, and actuarial teams to support financial accuracy, regulatory compliance, and proactive cost containment,

Key Responsibilities:

Clinical Review & Reserve Setting

• Conduct in-depth clinical reviews of cancer, transplant, neonate, and other high-cost complex medical claims, gathering relevant information from claim notices, filings, reporting and Pre-Certs, utilizing clinical resources to determine treatment plans.
• Assess claim severity, estimate ongoing costs, and recommend appropriate reserve amounts based on medical findings and contractual terms.
• Adjust reserves proactively as new clinical and claims information becomes available.

Reserve Monitoring & Clinical Reporting

• Monitor reserves daily, ensuring accuracy and compliance with established guidelines.
• Develop, maintain, and enhance reserve procedures, tools, and training for claims staff.
• Work with Claim Analysts in preparing and delivering monthly reserve summaries and analysis to executive leadership, actuary teams, and senior management.
• Identify and analyze reserve trends, researching underlying drivers to improve forecasting.

Collaboration & Education

• Partner with Medical Underwriting Nurses through renewal underwriting process of evaluating and assessing ongoing claims, provide clinical insight and recommendations to underwriting.
• Provide underwriting teams with clinical insight and cost information on reserving strategies.
• Serve as clinical and cost containment resource to other departments including Claims, Underwriting, Legal, and Actuarial.
• Educate internal staff and third-party administrators on clinical aspects influencing claim trends and cost.

Process Improvement & Compliance

• Contribute to process evaluations and workflow improvements to enhance reserve-setting efficiency and accuracy.
• Stay informed of industry changes, regulations, and best practices in medical underwriting, claims management, and reserve setting.
• Ensure all activities comply with corporate policies, procedures, and applicable laws.

Education, Experience & Knowledge:

• Required Registered Nurse (RN) designation, BSN preferred

• 4 Year / Bachelor’s Degree in Nursing, Healthcare or related field

• Deep clinical knowledge across multiple specialties, including chronic conditions, high-cost claims and complex case management.
• Excellent critical thinking, decision-making, and risk evaluation skills
• Strong medical knowledge including International Classification of Diseases (ICD), Current Procedural Terminology (CPT), medical terminology, COBRA, and HIPAA
• Ability to interpret complex medical claims information for financial and operational decision-making skills.
• Strong written and verbal communication with emphasis on confidentiality, tact, and diplomacy.
• Proficient with Microsoft Office (Excel, Word, PowerPoint, etc.)

Tokio Marine offers a competitive salary and benefits package, including: 

• Generous paid time off (PTO), 12 paid company holidays,
• 401(k) Retirement Plan with 6% company match.
• Health and dental insurance, and vision plan available.
• Company-provided long-term disability and life insurance.
• Opportunities for advancement in a successful and growing organization.
• Flexible work schedules and a great work/life balance.
• Paid Parental Leave.
• Volunteer Time Off.
• Enjoy casual dress and work in a modern, comfortable office with free parking.
• Remote work schedule

The Tokio Marine HCC Group of Companies offers a successful, dynamic organization experiencing rapid growth and are seeking energetic and confident individuals to join our team of professionals. The Tokio Marine HCC Group of Companies is an equal-opportunity employer. Please visit www.tmhcc.com for more information about our companies.

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