Ullico Inc. is actively recruiting a Medical Review Specialist for our Silver Spring, MD office. The dynamic candidate will perform the following duties: DUTIES : Obtain and review complete claims information, including large claim and trigger diagnosis reports along with case management and clinical narratives notes on current and prospective stop loss clients. Estimate future costs of known ongoing medical conditions for the next policy period. Communicate these cost projection recommendations to underwriting staff in a timely manner. Review the medical necessity and appropriateness of hospital claims, physician charges, specialty drug costs, usage and provide recommendation, as needed. Gather and analyze clinical information and medical records from plan &/or their administrators for cost containment and future cost determination; Maintain a close working relationship with plan administrators, vendors, third party payers, employers and re-insurers. Interpret documents such as medical reference books, patient medical records, charges, summary plan descriptions, stop loss insurance benefits to evaluate liability/compensability and to make recommendations. Compose clinical correspondence and communicate effectively with employees, employers (clients), TPA claims administrators, claims and underwriting staff and executive management regarding current care and alternative treatments. Apply clinical knowledge to make determinations on medical necessity. Troubleshoot complex clinical problems and practice independently without supervision of another licensed professional. Assess medical needs, care requirements and alternatives; monitor and follow up with the Plan Administrator, Plan's case management vendors, etc. regarding the planning, coordination and progress of treatment; evaluate and recommend alternative treatments/facility, as necessary to facilitate quality, cost-effective medical care for high risk individuals, trigger diagnoses and transplant losses. Provide cost containment initiatives by managing an inventory of Stop Loss claims (involving large case management, trigger diagnosis or transplant network losses), securing additional discounts from providers (either directly or through a preferred vendor), negotiating prices for medical services and supplies, negotiating settlements, developing transplant networks, evaluating losses, working closely with claims examiners on appropriateness of services/charges and educating clients and stop loss team about cost-effective alternatives. Prepare monthly report on all large case management. Communicate daily regarding large cases to the appropriate individuals. MINIMUM QUALIFICATIONS: The successful candidate must have a Bachelor's Degree with three to five years of experience as a health professional with a RN licensure. Excellent written and oral communication skills and attention to detail are critical for this role. Broad range of HIPAA regulations is required. Candidate must be proficient in Microsoft Word and Excel. For over 90 years, Ullico, the only labor-owned insurance and investment company, has been a proud partner of the labor movement, keeping union families safe and secure. From insurance products that protect union members, leaders and employers, to investments in building projects that have created thousands of union jobs, our customers continue to trust us with protecting their families, employees, businesses and investments. We offer a competitive starting salary and an outstanding benefits package including health/dental/vision, 401(k) and pension plan.