Communitas provides RN clinical reviews that assist with risk management services related to the stop loss review process. It is the goal of Communitas to promote a thorough understanding of clinical needs and expected claims costs associated with those identified needs. The RN evaluates and assesses clinical and claims data to identify and quantify known and potential risk. After evaluating the data, the nurse will propose effective clinical risk management strategies, providing concise, detailed reporting of data analysis findings, observations, and recommendations around the findings.
The utilization of predictive software to assist in the review process allows for state or region-specific projections. The RN clinical review provides valuable catastrophic and potentially catastrophic claim insight to assist with pricing and setting terms on prospective and renewal customers.