RN, Data Analyst

Role overview Coordinate risk oversight and care management for high-risk members covered by stop-loss plans. The work combines clinical assessment with claims analysis and collaboration across care delivery, pharmacy, sales, and account teams to support appropriate care and transitions.

Responsibilities - Identify and assess potential high-risk members in prospective and current groups using medical and pharmacy claims and risk tools. - Evaluate clinical needs against established guidelines and support medically appropriate levels of care and transitions. - Engage members in care management and coordinate with internal teams, providers, family, employers, and other supporters as appropriate. - Help maintain care protocols for members receiving care outside the service area and support use of specialized centers when suitable. - Work with pharmacy management on specialty drug use and site-of-service decisions; analyze care variances and contribute to quality improvement. - Support underwriting risk reviews and respond to information requests about large claims.

Requirements - Active Registered Nurse license in New Jersey. - At least two years of clinical experience, three years in the healthcare delivery system or industry, and two years of payer experience. - Understanding of health and prescription insurance products, eligibility, care management principles, and healthcare delivery systems. - Strong interpersonal skills and ability to coordinate across departments and with external stakeholders. - Proficiency with Windows-based software and Microsoft Office.

Nice to have - Associate’s or bachelor’s degree in nursing or a health-related field, or an accredited nursing diploma. - Case management or relevant clinical specialty certification; advanced Excel, SQL, Tableau, dashboard, or reporting experience. - Knowledge of stop-loss reporting, risk mitigation, and high-claimant identification and management.

Benefits and work setup - Salary range: $79,100–$105,945, with health, dental and vision coverage, retirement plans, paid time off, incentive plans, wellness programs, paid volunteer time, and tuition reimbursement. - Employees must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.