Key Facts

Remote From:

Andorra

Category: Risk Management Specialist

Freelance

Senior (5-10 years)

English

Hard Skills

Casualty Insurance Clinical Nursing Nurse Licensure Compact Utilization Management Underwriting Pharmaceuticals Clinical Documentation

Other Skills

•
Communication
•
Problem Solving
•
Teamwork
•
Time Management

Roles & Responsibilities

5+ years of direct clinical nursing experience in an acute care setting such as ICU, oncology, transplant, surgical, or complex chronic disease management
Active, unencumbered RN license; compact state license strongly preferred
3+ years of case management, utilization review, or payer-side experience
CCM (Certified Case Manager) certification

Requirements:

Review stop-loss claim notices and claimant medical records to identify high-cost trajectories before excess loss is incurred
Produce written clinical assessments that translate prognosis and treatment trajectory into actionable underwriting guidance
Advocate directly with stop-loss carrier partners for laser reduction or removal at renewal
Deliver clinical education to internal staff, TPA partners, and the adviser network on high-cost diagnoses

Job description

This is a remote position.

The Role

Your clinical assessments will directly influence millions of dollars in stop-loss decisions. When a case gets complex, expensive, or both — you are the person underwriters, TPAs, and consortium employers rely on. This is not care coordination or utilization review. It is clinical risk intelligence, and the financial stakes are real.

You will work at the intersection of claims, underwriting, and member outcomes. Your written assessments inform attachment points and renewal strategy. Your advocacy can remove or reduce lasers at renewal. Your early identification of catastrophic case trajectories protects employers from exposure they didn't see coming. This role has consequence.

What You’ll Do

Clinical Risk Review

Review stop-loss claim notices and claimant medical records to identify high-cost trajectories before excess loss is incurred, protecting consortium employers from avoidable exposure

Produce written clinical assessments that translate prognosis and treatment trajectory into actionable underwriting guidance, including recommendations on self-funded attachment points and stop-loss limits

Flag catastrophic case exposure to leadership as soon as identified, with reserve recommendations and clear risk narrative. Nothing catches us or our employers off guard

Stop-Loss & Renewal Advocacy

Advocate directly with stop-loss carrier partners for laser reduction or removal at renewal, using documented prognosis data, case management activity, and clinical evidence to support your position.

Partner with TPAs and external case managers as Virtue Health's clinical resource on complex and catastrophic cases, facilitating better financial and clinical outcomes for claimants and employers alike.

Program Development

Deliver clinical education to internal staff, TPA partners, and the adviser network on high-cost diagnoses, pharmaceutical cost trends, and emerging clinical developments that affect claims exposure

Evaluate new cost containment vendors, specialty case management resources, and preferred provider options to strengthen the tools available to consortium employers

Drive continuous improvement in Virtue Health's cost containment program, this function is early-stage and you will have significant influence over how it is built

Drive continuous improvement in Virtue Health’s cost containment program by evaluating new vendor partners, clinical tools, and care management resources that strengthen outcomes across the consortium

What You Bring

Must-Haves

5+ years of direct clinical nursing experience in an acute care setting such as ICU, oncology, transplant, surgical, or complex chronic disease management

Active, unencumbered RN license; compact state license strongly preferred given the remote and multi-state nature of the work

3+ years of case management, utilization review, or payer-side experience at a TPA, HMO, PPO, stop-loss carrier, or reinsurance firm

Working knowledge of how stop-loss insurance, self-funded health plans, and TPA operations work, you can hold your own in a conversation with an underwriter

CCM (Certified Case Manager) certification

Great to Have

Direct experience working with a stop-loss carrier, consortium, or reinsurance firm in a clinical review or medical risk capacity

Experience in laser advocacy, stop-loss renewal support, or clinical prognosis documentation for underwriting purposes

Deep familiarity with high-cost pharmaceutical trends, specialty and gene therapy drugs, and their downstream claims impact on self-funded plans

BSN or higher

You’re a Fit If You…

Thrive in a fast-paced environment and treat ambiguity as an opportunity, not a roadblock.

Hold yourself to a high standard and then raise it.

Own your results. No excuses, no hand-holding, just solutions.

Operate with integrity in everything you do, even when no one is watching.

Show up consistently, follow through on every commitment, and do it well.

Push yourself and the people around you to be better and mean it.

Take feedback as fuel, not criticism. You’re always learning.

Get genuinely energized by turning clinical knowledge into financial outcomes and see cost containment as a form of advocacy for employers and the people they cover.

Compensation & Benefits

We pay for performance and reward people who step up. In addition to your base, you’re eligible for: