Senior Clinical Risk Consultant

We’re in this for the greater good at ParetoHealth. Our mission is collective greatness, nothing less will do. Our team is a single force united in the drive to transform employee health benefits. The company was founded in 2011 to help small and medium-sized businesses fight the rising cost of employee health benefits. We blazed the trail with financing innovations that reduce the risks in self-insurance and deliver significant savings—and we continue to lead with a growing ecosystem of partners and world-class cost control solutions. But success is measured by more than dollars alone and we measure ours by the good that comes from knowing that every client and all their employees can count on effective, affordable healthcare for years to come. Please note that ParetoHealth does not provide employment visa sponsorship for this position. Candidates must be authorized to work in the United States without sponsorship both now or in the future. Position Summary: The Sr. Clinical Risk Consultant plays a critical role in supporting stop loss underwriting by providing clinical expertise, risk assessment, and cost projections for high-cost claimants and emerging risks. This role partners closely with underwriting to evaluate medical conditions, treatment plans, and potential financial exposure, enabling informed underwriting decision-making. Key Responsibilities: Clinical Risk Assessment Review medical records, diagnoses, and treatment plans for individuals and groups with high-cost or complex conditions Assess severity, prognosis, and likely progression of illnesses or injuries Identify potential high-risk cases, including transplant, oncology, neonatal, and chronic conditions Cost Projection & Financial Modeling Support Develop evidence-based cost projections for ongoing and future treatment Evaluate treatment pathways, including standard of care and emerging therapies Estimate timing and magnitude of claims exposure for underwriting purposes Underwriting Collaboration Partner with underwriters to provide clinical insight on risk selection, pricing, and policy terms Support new business and renewal underwriting with case-specific analysis Assist in determining appropriate laser levels, exclusions, or coverage strategies Treatment & Utilization Review Analyze appropriateness of care, site of service, and utilization patterns Identify opportunities for cost containment or alternative treatment strategies Monitor large claims and ongoing cases for changes in risk or cost trajectory Data Interpretation & Reporting Translate complex clinical information into clear, actionable summaries for non-clinical stakeholders Document findings, assumptions, and rationale for cost projections Contribute to reporting on high-cost risks and emerging clinical trends Market & Clinical Knowledge Stay current on medical advancements, specialty drugs, gene therapies, and high-cost treatments Understand healthcare cost drivers and reimbursement trends impacting stop loss risk Required Skills & Qualifications: Education & Licensure Active Registered Nurse (RN) license required Bachelor of Science in Nursing (BSN) preferred Experience 5+ years of clinical experience (e.g., ICU, oncology, case management, or utilization review) Experience in stop loss, health insurance, underwriting support, or large claims review strongly preferred Familiarity with high-cost conditions (e.g., transplants, cancer, NICU, specialty pharmacy) Skills & Competencies Strong analytical and critical thinking skills Ability to interpret medical records and translate into financial risk insights Knowledge of medical cost drivers and treatment protocols Excellent written and verbal communication skills Detail-oriented with the ability to manage multiple cases simultaneously Technical Skills Proficiency in Microsoft Office (Excel, Word, Outlook) Experience with underwriting platforms, or clinical review tools preferred Preferred Qualifications: Experience with stop loss carriers, TPAs, or health plans Exposure to underwriting processes Knowledge of specialty pharmacy and emerging therapies (e.g., gene/cell therapy) Key Attributes for Success: Ability to bridge clinical insight with financial and underwriting perspectives Strong collaboration skills across clinical and non-clinical teams Sound judgment in assessing risk with incomplete or evolving information Curiosity and continuous learning mindset around healthcare trends Perks & Benefits: Fully paid medical, dental, and vision benefits. Flexible PTO 401k company contribution Tuition reimbursement Professional development allowance Transportation allowance and daily parking reimbursement  Engaging hybrid work environment We are guided by our values: Fire in the belly The drive to learn, to improve, and to deliver outstanding value every day. See the field The ability to see the big picture and prepare to meet tomorrow’s needs. Get it done right The passion to produce at higher rates and to the highest standards. For the greater good A united community creating better health benefit solutions for all. Please note that any communication from our recruiters and hiring managers at ParetoHealth about a job opportunity will only be made by a ParetoHealth employee with an @paretohealth.com address. ParetoHealth does not conduct text message or chat-based interviews. Any other email addresses, agencies, or forums may be phishing scams designed to obtain your personal information. We will not ask you to provide personal or financial information, including, but not limited to, your social security number, online account passwords, credit card numbers, passport information, and other related banking information until we begin onboarding activities, which will be coordinated by a member of the ParetoHealth People Ops Team with an @paretohealth.com email address. Disclosures: ParetoHealth is an Equal Opportunity Employer and does not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in any of its activities or operations. These activities include, but are not limited to, hiring and firing of staff, selection of volunteers and vendors, and provision of services. We are committed to providing an inclusive and welcoming environment for all members of our staff, clients, volunteers, subcontractors, vendors, and clients. California Applicants:  See https://nam11.safelinks.protection.outlook.com/?url=https%3A%2F%2Furldefense.proofpoint.com%2Fv2%2Furl%3Fu%3Dhttps-3A__nam12.safelinks.protection.outlook.com_-3Furl-3Dhttps-253A-252F-252Fparetohealth.com-252Fccpa-2Dnotice-2Dof-2Dcollection-2Dfor-2Dcalifornia-2Demployees-2Dand-2Dapplicants-252F-26data-3D05-257C01-257Cgepelbaum-2540kandrlaw.com-257C3b8eb39de5414ab0912008dab74c041c-257C28c159782b9d4df688ab7e46f66dc5ea-257C1-257C0-257C638023834373928089-257CUnknown-257CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0-253D-257C3000-257C-257C-257C-26sdata-3DgdzaoyPob7lays6eHwaktcyRJ58gjJqo1Fayw2vP81E-253D-26reserved-3D0%26d%3DDwMFAg%26c%3DeuGZstcaTDllvimEN8b7jXrwqOf-v5A_CdpgnVfiiMM%26r%3D8zfxDor8Be3yZFvWj5kgqvG-AUiFrOG2BrJtvuJJh2E%26m%3DhZzabuHFbAe1JLsfqumvf1MT_YigCi2HLNE-vvgIpGg%26s%3DWMoCrGO7mTjOMibzDjTrWhbDcZNe2ajVMIEsz0LD2E4%26e%3D&data=05%7C01%7Chancock%40paretohealth.com%7C84864ceb95084c4eff4a08dab832553d%7C240fe352c11840d4ae4c62e5a43b2453%7C0%7C0%7C638024823613152533%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=X0FSOftLJMBhRHicvhMOX2etbukVOqED9LRrZWSlk1A%3D&reserved=0 for information about how Pareto Captive Services, LLC, Pareto Health, LLC, and Pareto Underwriting Partners, LLC, together with their respective subsidiaries (collectively, “Pareto”) collects and uses personal information submitted by employment applicants. Offices: Remote (Remote);