Clinical Operations Specialist, Medical Stop Loss - Remote

Job Description

Responsibilities

• Receive, track, identify and analyze claims data and clinical information as appropriate for the pre‑renewal, medical underwriting and cost containment processes, and provide communication and support for clinical review, cost containment teams and underwriting.
• Accurately set up incoming and outgoing referral and review documents, utilizing medical underwriting and cost containment platforms including intake logs, Conexure, Access, SharePoint, OneDrive, etc. as well as external SaaS.
• Remain compliant with all company and department policies and procedures and service level agreement standards.
• Execute system‑based reports for use by management to monitor department‑wide activity and performance.
• Demonstrate a solid work ethic and maintain a positive attitude.
• Collaborate effectively with fellow team members to address incoming work with the utmost efficiency.
• Track and assign notices and cost containment referrals to appropriate parties or teams systematically.
• Refer claimants for reserves and cost containment according to department guidelines; recognize more complex issues and request guidance in resolving them when needed.
• Utilize data manipulation techniques in Excel, PDF, Word, etc. to prepare referral files for clinical review.
• Stay informed of and participate in key IT system functions and updates currently being utilized for all stop‑loss programs within the scope of the Clinical Operations Specialist’s responsibilities.
• Create and generate reports based on business need.
• Communicate verbally and in writing about all activities and problems within the assigned area of responsibility with team and manager.
• Provide excellent customer service/communications by responding in a timely and appropriate manner to all internal and external clients.
• Handle other special projects as required.

Qualifications

• Bachelor’s degree from an accredited college or university required.
• Employer Stop Loss claims/notification experience preferred.
• Advanced PC skills including Excel, Word, Outlook, SharePoint/OneDrive storage, etc.
• Experience with medical terminology and claim coding preferred.
• Demonstrated ability to deliver high‑level customer service and ensure customer satisfaction.
• Ability to acutely prioritize and reprioritize workload as needed, especially during high referral volume.
• Focus on accuracy when completing all projects.
• Show sustained effort and dedication to getting the job done well, working continuously to produce superior work regardless of obstacles or setbacks.
• Display personal concern, interest, pride and accountability in all areas of responsibility.
• Ability to work both independently and in a team environment.
• Strong organization, critical thinking and time‑management skills with exceptional attention to detail.
• Ability to clearly present information through spoken or written word; read and interpret complex information with moderate supervision.
• Quick learner with willingness and ability to acquire new skills.

Benefits

• Competitive compensation package.
• Generous 401(k) employer match.
• Employee Stock Purchase plan with employer matching.
• Generous paid time off.
• Excellent benefits that go beyond health, dental & vision. Programs focused on entire family wellness, including physical, mental and financial wellbeing.
• A core tenet of ownership of career development, with tuition reimbursement, industry‑related certifications and professional training to support ongoing progress.
• A dynamic, ambitious, fun and exciting work environment.
• Commitment to social and community responsibility, matching donation program, volunteer opportunities and employee‑driven corporate giving program.

At C&F you will BELONG.

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Crum & Forster is committed to ensuring a workplace free from discriminatory pay disparities and complies with applicable pay equity laws. Salary ranges for this location are from $46,000.00 to $86,500.00, determined by factors such as market pay, responsibilities and skills required, and employee performance. Eligible employees may also participate in discretionary equity (stock) based compensation and/or performance‑based variable pay programs.