Medical Risk Consultant (RN)

Job Description

About Us

Virtue Health operates a Private Stop Loss Consortium that gives mid-size employers a better way to self-fund their health benefits. By pooling risk across employers, we reduce volatility, increase transparency, and deliver real control over healthcare spending. Outcomes that legacy fully insured and captive models consistently fail to produce.

We are a lean team that moves fast. Everyone here owns their domain, builds what's needed, and holds themselves accountable for results. If you want to be handed a playbook, this isn't the right fit. If you want to build one, keep reading.

The Role

Your clinical assessments will directly influence millions of dollars in stop-loss decisions. When a case gets complex, expensive, or both — you are the person underwriters, TPAs, and consortium employers rely on. This is not care coordination or utilization review. It is clinical risk intelligence, and the financial stakes are real.

You will work at the intersection of claims, underwriting, and member outcomes. Your written assessments inform attachment points and renewal strategy. Your advocacy can remove or reduce lasers at renewal. Your early identification of catastrophic case trajectories protects employers from exposure they didn't see coming. This role has consequence.

What You’ll Do

Clinical Risk Review

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• Review stop-loss claim notices and claimant medical records to identify high-cost trajectories before excess loss is incurred, protecting consortium employers from avoidable exposure
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• Produce written clinical assessments that translate prognosis and treatment trajectory into actionable underwriting guidance, including recommendations on self-funded attachment points and stop-loss limits
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• Flag catastrophic case exposure to leadership as soon as identified, with reserve recommendations and clear risk narrative. Nothing catches us or our employers off guard
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Stop-Loss & Renewal Advocacy

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• Advocate directly with stop-loss carrier partners for laser reduction or removal at renewal, using documented prognosis data, case management activity, and clinical evidence to support your position.
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• Partner with TPAs and external case managers as Virtue Health's clinical resource on complex and catastrophic cases, facilitating better financial and clinical outcomes for claimants and employers alike.
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Program Development

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• Deliver clinical education to internal staff, TPA partners, and the adviser network on high-cost diagnoses, pharmaceutical cost trends, and emerging clinical developments that affect claims exposure
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• Evaluate new cost containment vendors, specialty case management resources, and preferred provider options to strengthen the tools available to consortium employers
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• Drive continuous improvement in Virtue Health's cost containment program, this function is early-stage and you will have significant influence over how it is built
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• Drive continuous improvement in Virtue Health’s cost containment program by evaluating new vendor partners, clinical tools, and care management resources that strengthen outcomes across the consortium
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What You Bring

Must-Haves

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• 5+ years of direct clinical nursing experience in an acute care setting such as ICU, oncology, transplant, surgical, or complex chronic disease management
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• Active, unencumbered RN license; compact state license strongly preferred given the remote and multi-state nature of the work
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• 3+ years of case management, utilization review, or payer-side experience at a TPA, HMO, PPO, stop-loss carrier, or reinsurance firm
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• Working knowledge of how stop-loss insurance, self-funded health plans, and TPA operations work, you can hold your own in a conversation with an underwriter
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• CCM (Certified Case Manager) certification
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Great to Have

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• Direct experience working with a stop-loss carrier, consortium, or reinsurance firm in a clinical review or medical risk capacity
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• Experience in laser advocacy, stop-loss renewal support, or clinical prognosis documentation for underwriting purposes
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• Deep familiarity with high-cost pharmaceutical trends, specialty and gene therapy drugs, and their downstream claims impact on self-funded plans
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• BSN or higher
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You’re a Fit If You…

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• Thrive in a fast-paced environment and treat ambiguity as an opportunity, not a roadblock.
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• Hold yourself to a high standard and then raise it.
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• Own your results. No excuses, no hand-holding, just solutions.
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• Operate with integrity in everything you do, even when no one is watching.
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• Show up consistently, follow through on every commitment, and do it well.
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• Push yourself and the people around you to be better and mean it.
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• Take feedback as fuel, not criticism. You’re always learning.
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• Get genuinely energized by turning clinical knowledge into financial outcomes and see cost containment as a form of advocacy for employers and the people they cover.
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Compensation & Benefits

We pay for performance and reward people who step up. In addition to your base, you’re eligible for:

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• Performance bonus: up to 10% of base tied to measurable cost containment outcomes (MBO)
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• Health and Dental insurance
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• Life, short-term and long-term disability insurance
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• 401(k)
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• PTO
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Travel: Up to 10% for consortium events, TPA partner visits, and industry conferences

Our Hiring Process

Here’s how our process typically runs. Steps may vary depending on the role.

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• Pre-Screening Assessment
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• Screening
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• Assessments (Cultural fit and, depending on the role, a skills assessment)
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• Interview
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• Interview
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• Offer
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Ready? Let’s Go.

Join us. Build something that matters.