Lead Medical Insurance Risk Consultant/ Registered Nurse

At QBE, our purpose is to give people the confidence to achieve their ambitions inside and outside of work. From development opportunities, to flexible work options and highly competitive reward and benefits packages, we understand the importance of living our values when it comes to our people. Everything we do at QBE is underpinned by our company's cultural elements - because we know it's not just what we do that matters, it's how we do it that makes the difference.

This opportunity is accountable for utilizing knowledge and expertise to execute risk assessments, and risk control evaluation. Medical Risk Nurse Consultants provide QBE Medical Stop Loss Underwriters, QBE Claims Analysts and external clients clinical assessment of claimants anticipated care needs and potential costs associated with those needs. Additionally, Medical Risk Nurse Consultants work to facilitate appropriate benefit decisions and the use of unique solutions to ensure optimal claims outcomes.

•\tFoster effective risk decision-making within area of responsibility by completing complex risk assessments on new and renewal business and by consulting with QBE Underwriting, Claims Analysts and External clients as appropriate on high cost claims and implementing effective clinical risk management solutions by determining the need for any specialty resources or contracts
•\tFacilitate timely and accurate intake, triaging, tracking and documentation of potential/actual claims. Quickly, thoroughly, and correctly assess a potential/actual claim situation, determine need to impact, develop a sound strategy and successfully influence stakeholders to produce a meaningful clinical and/or financial outcome.

Primary Responsibilities
• Ensure effective risk management.
• Perform the review and assessment of new business and renewal large claims/disclosure to identify known and potential risk
• Assist underwriters in the evaluation and assessment of clinical and claims data to identify and quantify known and potential risk through the provision of concise, detailed, and accurate reporting of data analysis findings, observations and recommendations to underwriting.
• Effectively explain complex clinical conditions to a lay person
• Develop and maintain strong client, TPA and vendor relationships
• Consult with clients and TPAs on case management issues, alternative levels of care, program development, quality improvement, claim issues, and educational needs
• Participate in TPA implementation calls
• Perform timely and accurate tracking and documentation of probable and actual claims along with timely and thorough assessment of a probable/actual claims to determine the need to impact, develop a cost mitigation strategy and work with internal as well as external stakeholders to produce an effective clinical and financial outcome.
• Assist with medical necessity determinations and claim audits.
• Perform, as needed; transplant and other complex/catastrophic care reviews including review of treatment plan for medical necessity/experimental treatment, appropriateness of setting and coordination of any necessary additional review with outside medical expert
• Consult with internal and external clients on high cost claims and successfully engages effective clinical risk management strategies.
• Determine need for extra contractual agreements and/or engagement of specialty resources and acts as a liaison until claim is complete
• Serve as the lead resource for claims and underwriting related to risk management of A&H claims
• Establish reserve recommendations
• Build strong relationships with internal (UW's, Claims, Policy, Managers) and external clients (TPA's, external CM's) through individual credibility and applying business acumen to communicate risk factors, resolve complex inquiries and develop recommendations for continuous improvement and alignment with overall A&H risk strategy
• Utilize a comprehensive approach to risk mitigation within area of responsibility by monitoring regulatory changes to ensure on-going adherence to reporting requirements
• Develop a long-term approach to risk mitigation by performing scenario analyses for future risks and communicating with managers to share recommendations for mitigation and loss control
• Contribute to a positive environment by demonstrating cultural expectations and guiding leaders to reward performance and value "can do" people, accountability, diversity and inclusion, flexibility, continuous improvement, collaboration, creativity and fun
• Adopt QBE values in personal work behaviors, decision-making, contributions and interpersonal interactions; manage own career development by soliciting feedback and valuing other perspectives

Required Qualifications
Education: Bachelor's Degree or equivalent combination of education and work experience

Experience:7 years relevant experience

Licenses/Certifications: RN license required

Preferred Qualifications
Licenses/Certifications: CCM preferred


•working knowledge of Microsoft Excel

•working knowledge of relevant legal and requlatory requirements (preferred)

•working knowledge of insurance policy and contract language (preferred)

• Analyze complex risks to ensure organizational competitiveness and satisfaction of established long-range objectives; evaluate causal relationships
• Utilize effective research and investigative strategies
• Possess analytical and problem-solving skills
• Analyze and synthesize data to form options and recommendations
• Communicate outside and across the organization and share information as a positive aid to achieve best practice and objectives
• Effectively and efficiently present logic, reasoning, and analysis to others
• Able to set goals and handle multiple tasks, clients, and projects simultaneously; able to appropriately balance priorities, deadlines and deliverables. Able to quickly adapt to change, work under tight deadlines and stressful conditions.
• Expert negotiating, persuasion, and conflict resolution skills
• Must have excellent oral, written, and interpersonal communication skills. PC skills to include word processing, spreadsheet, and database applications. Intermediate typing skills.

• Apply business and financial acumen
• intermediate level or higher analytical and problem-solving skills
• High attention to detail
• Ability to work paperlessly
• Establish a high degree of trust and credibility with others
• Effectively present thoughts to key stakeholders to influence adoption of innovative recommendations
• Maintain regular and predictable attendance
• Ability to work well within a team and actively participate in team projects
• Build long-term collaborative working relationships with senior managers

QBE Cultural DNA

Everything we do at QBE is underpinned by our DNA (which interlinks seven cultural elements) - because we know it's not just what we do that matters, it's how we do it that makes the difference. We expect all employees to role model and inspire the right behaviors that link to our cultural elements:

• We are customer-centered

• We are technical experts

• We are diverse

• We are fast-paced

• We are courageous

• We are accountable

• We are a team

All employees are expected to adhere to QBE's Code of Ethics and Conduct and apply sound risk management practices

Work environment

Travel frequency: Occasional (approximately 5-10 trips annually)

Physical demands: General office jobs: Work is generally performed in an office environment in which there is not substantial exposure to adverse environmental conditions. Must have the ability to remain in a stationary position for extended periods of time. Must be able to operate basic office equipment including telephone, headset and computer. Incumbent must be able to lift basic office equipment up to 20 lbs.

To successfully perform this job, the individual must be able to perform each essential job

responsibility satisfactorily. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential job responsibilities.

The duties listed in this job description do not limit the assignment of work. They are not to be

construed as a complete list of the duties normally to be performed in the position or those

occasionally assigned outside an employee's normal duties. Our Group Code of Ethics and Conduct addresses the responsibilities we all have at QBE to our company, to each other and to our customers, suppliers, communities and governments. It provides clear guidance to help us to make good judgement calls.

Number of Openings:

How to Apply:

To submit your application, click "Apply" and follow the step by step process.

Equal Employment Opportunity:

QBE is an equal opportunity employer and is required to comply with equal employment opportunity legislation in each jurisdiction it operates.