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: www.cfins.com.

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:

1. Cost Containment & Clinical Risk Management

• Drive the development and implementation of advanced clinical risk management strategies for high-cost, complex claims.
• Analyze incoming cost containment referrals, evaluate clinical and claims data to identify and quantify risk, and engage effective cost containment strategies.
• Independently complete high-dollar negotiations, payment integrity reviews, complex medical necessity determinations, and high-profile claim audits.
• Analyze complex contracts (e.g., Transplant, CAR-T), recommend the best option, and facilitate access agreements.
• Validate or refute the appropriateness of stop-loss claim costs and establish reserve recommendations.
• Assist with the utilization of specialty networks and support the Director in overseeing the appeals process.

2. 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.

3. Client & Stakeholder Management

• Develop, maintain, and manage strong relationships with clients, Third-Party Administrators (TPAs), and vendors, championing exemplary customer service standards.
• Consult with clients and TPAs on case management, program development, quality improvement, and claim issues.
• Act as a senior point of contact for escalations and participate in TPA implementation calls as needed.

4. 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.
• Perform accurate and thorough data scrubbing of reports for underwriting reviews, using advanced tools.
• Collect data and create reports in collaboration with Digital Transformation and/or IT teams to streamline departmental processes.
• Identify and resolve data gaps and discrepancies to ensure comprehensive data for cost containment interventions.

5. Subject Matter Expertise & Communication

• Serve as a primary subject matter expert, articulating complex clinical conditions, pharmaceuticals, and risk structures to diverse audiences, including executive leadership.
• Stay informed on emerging therapies, technologies, and medical conditions, disseminating key information to internal and external stakeholders.
• Provide concise, detailed, and clear assessments, projections, and recommendations, effectively explaining complex scenarios to both technical and non-technical audiences.

6. Mentorship & Team Support

• Mentor and provide support and guidance for junior staff in areas such as complex claim evaluations, referral pathways, data best practices, and achieving organizational goals.

7. Operational Excellence & Compliance

• Support and explore new methods and processes to increase efficiency and achieve individual and organizational goals.
• Ensure compliance with all company policies, procedures, and service standards.
• Document all activities and outcomes accurately and promptly, keeping management informed of progress and potential issues.
• Maintain proficiency with all IT systems utilized by the Clinical Risk Management team.

What YOU will bring to C&F:

• Analytical & Operational Excellence: Possesses expert analytical, investigative, and problem-solving skills with the ability to interpret complex medical and risk reports. Highly organized and adaptable, capable of managing multiple tasks with exceptional attention to detail in a fast-paced environment.
• Communication & Relationship Management: Demonstrates excellent interpersonal, oral, and written communication skills, with a strong focus on customer satisfaction and building rapport. Expert in negotiation, persuasion, and conflict resolution.
• Professional Drive & Accountability: Exhibits a strong work ethic, personal accountability, and a commitment to producing high-quality, accurate work. A proactive, quick learner dedicated to getting the job done well.
• Collaboration & Mentorship: Proven ability to work effectively both independently and collaboratively within a team, with the capacity to mentor and guide junior staff.

Requirements:

• 5-10 years clinical experience with a current unrestricted licensure as a health professional (Registered Nurse)
• 5+ years of reinsurance or insurance industry experience required
• Bachelor’s degree from an accredited university or equivalent experience required and 8+ years of overall experience
• Strong PC skills including Excel, Word, Outlook
• Group medical, managed care, health insurance, stop loss or reinsurance experience required
• Strong knowledge of disease processes and treatment plans#LI-MS

#LI-MS

#LI-REMOTE

• Competitive compensation package
• Generous 401K employer match
• Employee Stock Purchase plan with employer matching
• Generous Paid Time Off
• Excellent benefits that go beyond health, dental & vision. Our programs are focused on your whole family’s wellness, including your physical, mental and financial wellbeing
• A core C&F tenet is owning your career development, so we provide a wealth of ways for you to keep learning, including tuition reimbursement, industry-related certifications and professional training to keep you progressing on your chosen path
• A dynamic, ambitious, fun and exciting work environment
• We believe you do well by doing good and want to encourage a spirit of social and community responsibility, matching donation program, volunteer opportunities, and an employee-driven corporate giving program that lets you participate and support your community

At C&F you will BELONG

If you require special accommodations, please let us know. We value inclusivity and diversity. We are committed to equal employment opportunity and welcome everyone regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender identity, or Veteran status. If you require special accommodations, please let us know

For California Residents Only:  Information collected and processed as part of your career profile and any job applications you choose to submit are subject to our privacy notices and policies, visit https://www.cfins.com/onlineprivacypolicy/ca/noticeatcollection/  for more information.

Crum & Forster is committed to ensuring a workplace free from discriminatory pay disparities and complying with applicable pay equity laws.  Salary ranges are available for all positions at this location, taking into account roles with a comparable level of responsibility and impact in the relevant labor market and these salary ranges are regularly reviewed and adjusted in accordance with prevailing market conditions. The annualized base pay for the advertised position, located in the specified area, ranges from a minimum of $105,800 to a maximum of $155,100. The actual compensation is determined by various factors, including but not limited to the market pay for the jobs at each level, the responsibilities and skills required for each job, and the employee’s contribution (performance) in that role. To be considered within market range, a salary is at or above the minimum of the range. You may also have the opportunity to participate in discretionary equity (stock) based compensation and/or performance-based variable pay programs.