Remote Partner, Clinical Claims Specialist (RN)

Davies Talent Solutions is partnering with a rapidly growing organization in the self-funded healthcare and alternative risk financing space to identify a Partner, Clinical Claims Specialist. This strategic role offers the opportunity to influence clinical risk management, underwriting decisions, and cost-containment strategies for employer-sponsored health benefit programs.

Position Overview

The Partner, Clinical Claims Specialist serves as a senior clinical resource responsible for evaluating complex medical claims, supporting underwriting decisions, and identifying opportunities to improve outcomes while managing healthcare costs. Working closely with underwriting, claims, operations, and external vendor partners, this individual will provide clinical expertise and strategic recommendations related to high-cost claimants, emerging medical risks, and claim management initiatives.

Key Responsibilities

• Conduct clinical reviews of large-loss claims, high-cost claimants, and ongoing risk exposures to support underwriting and risk assessment decisions.
• Provide claims support and consultation, including research, follow-up, and coordination efforts related to complex clinical cases.
• Analyze medical histories, treatment plans, provider information, and clinical data to assist with risk selection and pricing strategies.
• Collaborate with underwriting teams during new business evaluations, renewals, and risk reviews.
• Partner with internal stakeholders and external service providers on claim escalations, payment integrity reviews, and cost-management initiatives.
• Identify opportunities for early clinical intervention, case management, negotiation strategies, and alternative treatment pathways that may reduce financial exposure.
• Develop reporting and clinical analyses highlighting cost drivers, trend data, emerging risks, and potential savings opportunities.
• Serve as a clinical liaison with third-party administrators (TPAs), pharmacy benefit managers (PBMs), cost-management vendors, and reinsurance partners.
• Assist in the development and enhancement of clinical review processes, underwriting guidelines, and operational best practices.
• Stay informed on evolving treatment protocols, specialty pharmacy trends, high-cost therapies, and healthcare market developments.
• Collaborate across finance, operations, underwriting, and strategic business teams to support integrated risk management initiatives.
• Contribute clinical expertise to product development, risk management programs, and organizational growth initiatives.

Qualifications

• Registered Nurse (RN) or equivalent clinical credential required; BSN or advanced clinical certification preferred.
• 10+ years of experience in clinical risk management, medical underwriting, nurse consulting, utilization management, or healthcare cost containment.
• Strong understanding of stop-loss insurance, self-funded health plans, medical claim review, and large-loss claim analysis.
• Experience working with TPAs, carriers, MGUs, health plans, or alternative funding organizations preferred.
• Demonstrated ability to analyze complex medical information and communicate recommendations to both clinical and business stakeholders.

About the Opportunity

This is a high-impact position with a growing organization focused on innovative healthcare financing and risk management solutions. The role offers the opportunity to work with senior leadership, influence strategic decisions, and help improve both clinical and financial outcomes across a diverse portfolio of healthcare programs.

Davies Talent Solutions is managing this search on behalf of our client. Qualified candidates will receive additional company-specific information during the interview process.