Complex Claims Specialist
Dallas, Texas, United States of America
Claims
2500GB
Working at Lockton
At Lockton, we’re passionate about helping our people achieve their ultimate potential. Our people are curious, action-oriented and always striving to make ourselves and those around us better. We’re active listeners working to ensure understanding and problem solvers developing innovative solutions. If you can see yourself delivering excellent service to clients, giving back to our communities and being a part of our caring culture, you belong here.
Houston, Plano, St. Louis
Business unit
Lockton-Dunning Series
Salary
$65,600-$82,100
Schedule
Full-time
Lockton Benefits Offerings
Click Here
Workplace
Remote
Your Responsibilities
Lockton is currently seeking a Clinical Claims Specialist within our Specialty Practice unit. The objective of this role is to improve and reduce the severity of complex and catastrophic claims, reduce the cost of risk while improving the health of our employer client’s employee health plan.
- Provide explanation of disease states and associated costs to internal and external stakeholders.
- Provide cost-of-care estimates used in the risk assessment of stop loss underwriting.
- Consult with and advise underwriting on medical/clinical care approaches, standards of care and research of data for new business and renewals.
- Serve as a resource regarding medical necessity issues, standards of care and analysis for the reimbursement of submitted stop loss claims.
- Review claims and clinical documents to identify and monitor opportunities to increase member quality of care and overall cost reduction.
- Collaborate with various key stake holders to strategize clinical and cost savings strategies and assist on execution of plan.
- Coordinate implementation of claims savings solutions with Lockton Client Service Teams, TPAs, and stop loss carriers including regular tracking to measure savings and plan performance.
- Manage and organize task lists and open items and cases.
- Attend team clinical rounds to discuss cases and strategy solutions.
Qualifications
- Licensure as a RN or Bachelor’s in Healthcare Management or related field.
- A minimum of 5 years of clinical/risk management experience.
- Experience and/or knowledge of health insurance processes.
- CCM, NANCM, or other certification or designation is a plus.
- Working knowledge or experience in quality and care management.
- Proven time management experience.
- Strong organizational skills with ability to handle multiple tasks, in a fast-paced environment.
- Excellent oral and written communication skills.
- Ability to translate complex clinical topics and subjects to a non-clinical audience.
- Demonstrated advanced analytical and problem-solving skills.
- Working knowledge of Microsoft products (Word, Outlook, PowerPoint)
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Equal Opportunity Statement
Lockton Companies is proud to provide everyone an equal opportunity to grow and advance. We are committed to an inclusive culture and environment where our people, clients and communities are treated with respect and dignity.
At Lockton, supporting diversity, equity and inclusion is ingrained in our values, and we believe that we are at our best when we fully embrace everyone. We strive to cultivate a caring culture that learns from, celebrates and thrives because of our breadth of differences. As such, we recognize that recruiting, developing and retaining people with diverse backgrounds and experiences is vital and enabling our people to thrive personally and professionally is critical to our long-term success.
About Lockton
Lockton is the largest privately held independent insurance brokerage in the world. Since 1966, our independence has allowed us to serve our clients, take care of our people and give back to our communities. As such, our 10,000+ Associates doing business in over 100 countries are empowered to do what’s right every day.
At Lockton, we believe in the power of all people. You belong at Lockton.
How We Will Support You
At Lockton, we empower you to be true to yourself in all that you do. Your success is our success, and we provide opportunities to help you grow and create a rewarding career path, however you envision it.
We are ready to meet you where you are today, and as your needs change over time. In addition to industry-leading health insurance, we offer additional options to support your overall health and wellbeing.
No Agencies Please
Any Employment Agency, person or entity that submits an unsolicited resume to this site does so with the understanding that the applicant's resume will become the property of Lockton Companies, Inc. Lockton Companies will have the right to hire that applicant at its discretion and without any fee owed to the submitting Employment Agency, person or entity. Employment Agencies, who have fee Agreements with Lockton Companies must submit applicants to the designated Lockton Companies Employment Coordinator to be eligible for placement fees.
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Diane McDaniel, Associate Director - Healthcare and Social Services Account Executive, has been making waves in the insurance industry since she joined the Phoenix office in 2021. Recently, she was honored with the prestigious Risk & Insurance Power Broker award, a testament to her dedication and expertise. Her passion for healthcare drove Diane's journey to Lockton. After taking four years to raise her daughters, she returned to the workforce with a renewed sense of purpose. Despite working with talented individuals at another broker, she felt the absence of a dedicated healthcare vertical. Healthcare had always been her passion, and she knew she needed to be in an environment that shared her enthusiasm. "My whole family is in healthcare," said Diane. "My sister is a nurse, my mom works in compliance for a hospital system, and my grandmas and aunts have all been in healthcare. I come from a service-type family, but I've always been business-minded. My service to other people is my business mind supporting people who serve on those front lines." Diane's desire to help healthcare systems manage risk and focus on patient care led her to Lockton. She soon discovered that it was the perfect fit for her. "I always heard Lockton had an ultra-competitive culture," Diane notes. "This initially made me nervous, but when I started working here, I quickly found my people. I had struggled for 20 years at different brokers because I am competitive and want to win. I always felt like people weren't at the same speed – but I quickly found out Lockton Associates were my people." When Diane joined Lockton, she expressed her desire to be an account executive and learn the book and clients she was working with. Shortly after, the team lead left, and Diane, being the senior member, stepped into the role.
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