Senior Clinical Risk Manager; Remote
Position: Senior Clinical Risk Manager (Remote) Crum & Forster Company Overview Crum & Forster (C&F), with a proud history dating to 1822, provides specialty and standard commercial lines insurance products through our admitted and surplus lines insurance companies. C&F enjoys a financial strength rating of "A" (Excellent) by AM Best and is proud of our superior customer service platform. Our claims and risk engineering services are recognized as among the best in the industry. Our most valuable asset is our people: more than 2500 employees in locations throughout the United States. The company is increasingly winning recognition as a great place to work, earning several workplace and wellness awards for four years running, including the 2025 Great Place to Work Award for our employee-first focus and our steadfast commitment to diversity, equity and Inclusion. C&F is part of Fairfax Financial Holdings, a global, billion dollar organization. For more information about Crum & Forster, please visit our website:
Job Description
Since 2000, Crum & Forster’s Accident & Health division (A&H) has offered a diverse portfolio of specialty insurance and reinsurance products nationwide. We place a strong focus on product development and creative distribution methods, along with excellent client service and support. In addition to our robust domestic portfolio, which spans both special risk and medical solutions, A&H works on an international basis through various partnerships. Our global capabilities provide our partners with even broader flexibility in underwriting solutions. The qualities and capabilities of Crum & Forster Accident & Health demonstrate our philosophy of building meaningful, long-term partnerships and our dedication to providing alternative strategies in an ever-changing insurance market. The A&H MBU takes a full-spectrum approach to designing and servicing a robust slate of products tailored to needs in Employer Stop Loss, Excess Medical, Life, and Ancillary and Supplemental benefits. Our diversified business model includes program partnerships as well as direct sales in Employer Stop Loss. At year-end 2023, the MBU recorded $741M in gross premium written. Information about the Role, Line of Business and Team: The Senior Clinical Risk Manager role utilizes a high level of experience and advanced knowledge regarding nursing, medical conditions, risk and prognoses as it relates to treatment plans and utilization of care. The Senior Clinical Risk Manager provides accurate current and next year cost projections and savings opportunities to C&F. What you will do
- Cost Containment & Clinical
Risk Management: Drive the development and implementation of advanced clinical risk management strategies for high-cost, complex claims.
- Cost Containment & Clinical
Risk Management: Analyze incoming cost containment referrals, evaluate clinical and claims data to identify and quantify risk, and engage effective cost containment strategies.
- Cost Containment & Clinical
Risk Management: Independently complete high-dollar negotiations, payment integrity reviews, complex medical necessity determinations, and high-profile claim audits.
- Cost Containment & Clinical
Risk Management: Analyze complex contracts (e.g., Transplant, CAR-T), recommend the best option, and facilitate access agreements.
- Cost Containment & Clinical
Risk Management: Validate or refute the appropriateness of stop-loss claim costs and establish reserve recommendations.
- Cost Containment & Clinical
Risk Management: Assist with the utilization of specialty networks and support the Director in overseeing the appeals process.
- Strategic Underwriting Partnership:
Act as a strategic partner to underwriting by evaluating complex clinical and claims data to identify, quantify, and advise on significant risks, directly influencing underwriting strategy and decisions.
- Client & Stakeholder Management:
Develop, maintain, and manage strong relationships with clients, Third-Party Administrators (TPAs), and vendors, championing exemplary customer service standards.
- Client & Stakeholder Management:
Consult with clients and TPAs on case management, program development, quality improvement, and claim issues.
- Client & Stakeholder Management:
Act as a senior point of contact for escalations and participate in TPA implementation calls as needed.
- Data Management, Analysis & Reporting:
Ensure accurate entry, validation, and analysis of cost containment, notification, and medical underwriting data within the claims system, maintaining high standards of data integrity.
- Data Management, Analysis & Reporting:
Perform accurate and thorough data scrubbing of reports for underwriting reviews, using advanced tools.
- Data Management, Analysis & Reporting:
Collect data and create reports in collaboration with Digital Transformation and/or IT teams to streamline departmental processes.
- Data Management, Analysis & Reporting:
Identify and resolve data gaps and discrepancies to ensure comprehensive data for cost containment interventions.
- Subject Matter Expertise &…
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