Stop Loss Nurse

Imagine360 is seeking a Stop Loss Nurse to join the team!  The Stop Loss Nurse is responsible for identifying, monitoring, and managing high-cost and complex medical claims that may exceed stop-loss thresholds, supporting timely reporting, cost-containment strategies, and compliance with stop-loss policy requirements. This role focuses on early identification of large claimants, clinical review of high-cost drivers, and coordination with internal and external stakeholders, and support for timely carrier notification. The nurse collaborates with internal teams, TPAs, employers, and stop-loss carriers to manage large claims and minimize financial risk to ensure high quality and cost effective care for members.

Position Location: 100% remote

Responsibilities include but are not limited to:

• Case Identification & Review
  • Identify potential high-cost claims that may reach or exceed stop-loss thresholds through review of claims data, utilization trends, trigger diagnosis reports, and referral sources.
  • Review medical records, claims data, and treatment plans and utilization patterns to clinical and financial drivers identify high-cost claims.
  • Track and monitor ongoing claims approaching stop-loss thresholds and escalate as appropriate for reporting and intervention.
• Clinical & Claim Evaluation
  • Review high cost and catastrophic medical claims to ensure policy compliance, and clinical appropriateness of services.
  • Evaluate complex cases and develop clinically informed summaries of current status, expected treatment trajectory, and projected future costs exposure for stop-loss reporting and underwriting support. Analyze catastrophic and high acuity episodes of care to identify ongoing risk, cost drivers and opportunities for intervention.
  • Review potential claim notices, high-cost claimant reports, trigger diagnosis reports, and referrals from UM, CM, DM or brokers/clients to evaluate cost exposure and determine next steps.
• Cost Containment & Utilization Management
  • Implement cost-containment strategies such as redirection to in-network or high-quality, cost-effective providers.
  • Collaborate with case management to manage high-cost therapies.
  • Support development of improved processes for identifying and flagging high cost claimants.
• Stop Loss Coordination
  • Collaborate with stop-loss carriers to submit timely notifications, updates, and required documentation
  • Prepare and manage large case reporting, including ongoing updates to stakeholders
  • Ensure compliance with stop-loss policy requirements and deadlines
• Data Analysis & Reporting
  • Maintain accurate documentation of case activities, outcomes, and cost savings
  • Analyze claim trends , recurring high-cost drivers, and emerging patterns, and provide insights to leadership and clients.
  • Prepare recurring and adhoc reports on large claims and potential exposures.
• Compliance & Quality Assurance
  • Adhere to all regulatory requirements, HIPAA guidelines, and internal policies.
  • Participate in audits and quality improvement initiatives.
  • Maintain clinical documentation standards that support audit readiness, reporting accuracy and defensible case decision-making

 

Required Experience/Education:

• A nursing degree from an accredited college, university, or school of nursing.
• 2+ years of clinical experience (e.g., acute care, ICU, oncology, or case management)
• 2+ years experience in case management, utilization review, or managed care
• Strong knowledge of medical terminology, healthcare delivery systems, and insurance processes

 

Preferred experience:

• Experience with stop-loss insurance, large claims, or self-funded health plans
• Certification in Case Management (CCM) or similar
• Experience with high-cost claims such as transplants, oncology, or specialty drugs
• Familiarity with claims systems and healthcare analytics

 

Skills and Abilities:

• Strong clinical assessment
• and critical thinking skills
• Excellent communication and interpersonal abilities
• Ability to analyze complex data and make cost-effective care decisions
• Negotiation and problem-solving skills
• Strong organizational skills and attention to detail
• Ability to work independently and collaboratively in a fast-paced environment

 

Licenses or Certification:

• Active, unrestricted Registered Nurse (RN) license from an accredited college, university, or school of nursing.
• Must maintain active, current, and unrestricted Registered Nurse license and CEU's as required by the State Board of Nursing. Must be willing to obtain and maintain additional license(s) as required to perform the job functions of the organization.
• Must obtain Certified Case Manager (CCM) designation within 3 years of hire.

 

What can Imagine360 offer you?

• Multiple Health plan options
• Company paid employee premiums for disability and life insurance
• Parental Leave Policy
• 20 days PTO to start / 10 Paid Holidays
• Tuition reimbursement
• 401k Company contribution
• Company paid Short & Long term Disability plus Life Insurance
• Professional development initiatives / continuous learning opportunities
• Opportunities to participate in and support the company's diversity and inclusion initiatives

 

Want to see our latest job opportunities? Follow us on LinkedIn

Imagine360 is a health plan solution company that combines 50+ years of self-funding healthcare expertise. Over the years, we've helped thousands of employers save billions on healthcare. Our breakthrough total health plan solution is fixing today's one-size-fits-none PPO insurance problems with powerful, customized, member-focused solutions.

Imagine360 is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.

 

**RECRUITMENT AGENCIES PLEASE NOTE: Imagine360 will only accept applications from agencies/business partners that have been invited to work on a specific role. Candidate Resumes/CV's submitted without permission or directly to Hiring Managers will be considered unsolicited and no fee will be payable. Thank you for your cooperation**