Description:
A CAREER AT TPAC
Working at TPAC, you’ll experience a culture that is made up of a group of people who are supportive, innovative, collaborative, and caring towards each other and the customers we serve. TPAC is looking for a Clinical Risk Nurse to join our team. This is a remote or hybrid, full-time position located in our Blaine, MN office depending on location. Join our team and help us change the way healthcare is financed, disclosed and delivered.
OUR VISION FOR THIS KEY ROLE
The Clinical Risk Nurse provides clinical expertise to support TPAC's underwriting and claims operations by evaluating medical risk, analyzing complex clinical data, and identifying cost drivers within the medical stop-loss portfolio. This role serves as the bridge between clinical knowledge and financial risk assessment — reviewing large claims, medical records, treatment plans, and diagnoses to inform underwriting decisions, pricing, and reserving. The Clinical Risk Nurse collaborates closely with underwriters, claims analysts, and leadership to ensure that TPAC's risk evaluation is grounded in clinical accuracy, supporting the company's mission of bringing transparency and innovation to healthcare financing.
Salary Range: $90,000 - $120,000
A SAMPLE OF WHAT YOU’LL GET TO DO IN THIS JOB
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Review and evaluate medical records, clinical documentation, treatment plans, and diagnoses to assess risk severity, prognosis, and potential claim exposure for new business and renewal cases
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Provide clinical insights and recommendations to underwriters on complex or high-exposure cases involving catastrophic, chronic, or specialty conditions
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Analyze large claims and high-cost claimants, identifying trends in treatment, utilization, and cost drivers across the stop-loss portfolio
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Conduct medical risk assessments including evaluation of transplant cases, oncology protocols, neonatal care, specialty pharmaceuticals, and other high-cost conditions
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Develop and maintain clinical risk scoring models and reference tools to support consistent and accurate underwriting evaluations
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Monitor emerging medical trends, new treatment protocols, pharmaceutical developments, and regulatory changes that may impact claims costs and stop-loss pricing
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Collaborate with the Claims Department to review ongoing large claims, validate clinical appropriateness, and support reserving accuracy
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Assist with the identification and evaluation of potential cost containment strategies including case management referrals, centers of excellence, and utilization review opportunities
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Serve as a clinical subject matter expert for internal training, educating underwriting and claims staff on medical terminology, diagnoses, treatment pathways, and cost implications
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Prepare clinical summaries and risk reports for underwriting leadership, reinsurers, and client presentations
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Participate in TPA reviews and audits, evaluating the clinical accuracy and appropriateness of claims handling
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Support special projects and ad hoc clinical analyses as directed by leadership
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Partner with Third-Party Administrators (TPAs), brokers, and other stakeholders to proactively manage large and complex claims, identify risk mitigation strategies, and develop effective cost-containment solutions
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Track, analyze, and report identified and realized claim savings, providing insights and recommendations to support organizational risk management and financial objectives
Requirements:
WHAT YOU’LL BRING TO THE JOB
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Active Registered Nurse (RN) license required; Bachelor of Science in Nursing (BSN) preferred
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7+ years of clinical nursing experience, with a strong background in critical care, case management, utilization review, or risk management
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3+ years of experience in a stop-loss, reinsurance, health insurance, or managed care environment preferred
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Strong knowledge of medical terminology, disease processes, treatment protocols, and pharmaceutical therapies
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Familiarity with ICD-10, CPT, HCPCS coding systems and their application to claims and underwriting
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Understanding of self-funded health plans, stop-loss insurance, and reinsurance structures
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Excellent analytical skills with the ability to translate complex clinical information into financial risk assessments
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Strong written and verbal communication skills with the ability to present clinical findings to non-clinical audiences
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Detail-oriented with strong organizational skills and the ability to manage multiple cases and priorities simultaneously
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Proficiency in Microsoft Office Suite (Outlook, Excel, Word, OneNote)
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CCM, COHN, CPHRM, or other relevant clinical or risk management certifications a plus
WHO WE ARE
TPAC is a Managing General Underwriting firm located in Minneapolis, Minnesota. TPAC’s mission is to change the way healthcare is financed, disclosed and delivered. We need people who value honesty and transparency; people who take ownership and responsibility of whatever they are doing. We seek individuals who value all people and interact with humility and respect; people who like to dig deep into issues, who are curious and who understand life is about more than work. If you believe in TPAC’s mission and share our Core Values, then we would like to talk about how we can make a positive impact together.
