Summary
Overview
Work History
Education
Skills
Liscenses and Certifications
Timeline
Generic

Abibe Limani, BSN, RN

Wayne,NJ

Summary

Seasoned Registered Nurse with over 20 years of experience, a diverse clinical background in oncology, critical care, and the healthcare insurance industry, career advancing as a dynamic executive in medical stop-loss insurance. Skilled in developing and managing clinical underwriting teams and operations, strategic planning, and improving underwriting efficiency. Proficient in clinical and financial risk analysis, cost projection, and mitigation to drive profit growth. Demonstrated abilities in fostering positive relationships with stakeholders, partners, third party administrators and vendors, while delivering high-impact business results.

Overview

25
25
years of professional experience

Work History

Vice President of Clinical & Underwriting Operations

Captives Solutions & Options
Atlanta, GA
09.2024 - Current
  • Collaborating with the CEO to develop strategic plans that help develop processes to facilitate company growth within the stop-loss captives.
  • Developed a revised underwriting platform, consolidating interdisciplinary team data for information sharing.
  • Creating a modified process for an RFP (Request For Proposal) for high-prospect business groups based on a matrix score of 85% and above.
  • Calculating proposed stop-loss policy rates for new and renewal business by analyzing their claims experience, annual financial trend, current specific and aggregate premiums, specific deductibles, high-cost claimant risk analysis, and future cost projection.
  • Providing qualifying quotes to carriers for binding proposals.
  • Coordinating biweekly meetings with the underwriting carrier's executive leadership to discuss proposal progress and strategies contributing to business acquisition that would increase company revenue.
  • Collaborating with the executive sales team to obtain broker and TPA data for proposal binding.
  • Assessing group risk exposure, leveraging pharmaceutical discount opportunities with PBMs on drug therapies.
  • Managing the underwriting operations of junior team members (account managers, sales representatives, underwriters, etc.) to ensure accurate data retrieval, checks and balances of new and renewal business, and adherence to deadlines.

Director of Medical Underwriting Review

Pareto Health
Philadelphia, PA
04.2023 - 08.2024
  • Created a new company division which was established as the Medical Underwriting Review department, formed with a specialized team of RNs to support UW through clinical risk assessments.
  • Recruited, trained, and managed the RN staff of the Medical Underwriting team while conducting mid-year and end-of-the-year performance evaluations.
  • Created workflow policies and procedures, including nursing training manuals, to establish standard guidelines for medical review.
  • Partnered with IT in developing the underwriting portal for the transmission and uploading of clinical review reports across company systems.
  • Managed the department budget, authorized expenses, staff payroll, bonus percentages, and educational conferences.
  • Developed HR training modules for underwriters covering common clinical conditions, treatment processes, and costs.
  • Presented weekly updates to underwriters on emerging therapies, including gene and cell therapy.
  • Served as a clinical liaison and resource for account management, brokers, consultants, and vendors.
  • Participated in educational conferences focusing on new emerging therapies and treatments.

Stop Loss High Level Clinical Consultant Lead

Horizon Blue Cross & Blue Shield of
Newark, NJ
08.2018 - 03.2023
  • Pioneered the first clinical stop loss team as the sole nurse creating impactful outcomes resulting in the advancement to a a senior professional role.
  • Led the expansion of the clinical stop loss team, by hiring, training and managing the new nursing staff.
  • Prepared workflows on the process of clinical underwriting, and medical stop-loss nursing.
  • Conducted clinical evaluations to aid underwriting and sales teams in determining premium rates for high-risk business groups.
  • Produced $500,000 in cost savings in 2022 by partnering with pharmacy management, switching high-cost infusion settings, and utilizing generic
  • Participated in the pharmaceutical mandate, delivering Ocrevus treatments at home to eligible multiple sclerosis patients, with cost reductions totaling $1.3 million by the end of 2023.
  • Collaborated with the care management team to engage high-risk claimants in case management protocols for cost-effective care.

RN II, Commercial Risk Adjustment Management; Exchange Population

Horizon Blue Cross & Blue Shield of NJ
Newark, NJ
09.2015 - 08.2016
  • Performed high-level clinical data analysis of high-risk disease members of the Exchange population based on their Hierarchical Condition Category (HCC).
  • Collaborated with primary providers to ensure the accuracy of billed ICD codes, and the confirmation of diagnoses that were reported to the Centers for Medicare and Medicaid Services for cost reimbursement.
  • Provided one-on-one case management services to high-risk disease members.
  • Participated in multi-disciplinary workgroups for improving processes and patient outcomes.
  • Provided one on one training to all new hires.

RN I, Primary Nurse Case Management

Horizon Blue Cross & Blue Shield of NJ
Newark, NJ
10.2013 - 09.2015
  • Chosen by management as the pioneer RN case manager for a new Primary Nurse Model pilot program, which led to the implementation across additional national accounts in the company.
  • Delivered individualized, cost-efficient case management services, prior authorization requests, and coordinating hospital discharge planning according to medical guidelines.
  • Selected by management to deliver onsite disease management presentations, and one-on-one health coaching services to account employees.
  • Participated in quarterly evaluations of case management by third-party administrators.
  • Served as the main clinical liaison for the health benefit fair held on-site at a national client.

Staff Registered Nurse, Charge Nurse

Chilton Memorial Hospital
Pompton Plains, NJ
04.2000 - 09.2015
  • Delivered exceptional inpatient and outpatient nursing care across diverse clinical specialties including Oncology, Pediatrics, Maternity/Nursery, ICU, and Same Day Surgery.
  • Delivered multi-route chemotherapy, blood products, and specialized drug infusions to oncology and critical care patients.
  • The charge nurse in critical care nursing is responsible for preparing staffing assignments and emergency crisis roles.

Education

Associate Degree - Nursing

Felician University
Lodi, NJ

Bachelors of Science - Nursing

Saint Peter's University
Jersey City, NJ

Skills

  • Leadership, with team development and management
  • Creating policies and process improvements
  • Budget management
  • Interpreting complex medical records for high-cost drivers, the trajectory of disease progression, and known treatment protocols
  • Assessing clinical risk and financial forecasting
  • Evaluating complex cases and identifying lasers
  • Supporting clinical decisions with evidence-based medicine
  • Analyzing annual financial trends and stop-loss ratios
  • Understanding self-funded, level-funded, and fully insured policies
  • Strong verbal and written communication

Liscenses and Certifications

  • Professional Registered Nurse licensed in NJ, NY and hold a Multi-State Compact Licensure
  • Patient Care Coordinator Certificate, Duke University, Raleigh, NC
  • The Oncology Nursing Society Chemotherapy Certification, Memorial Sloan Kettering Hospital

Timeline

Vice President of Clinical & Underwriting Operations

Captives Solutions & Options
09.2024 - Current

Director of Medical Underwriting Review

Pareto Health
04.2023 - 08.2024

Stop Loss High Level Clinical Consultant Lead

Horizon Blue Cross & Blue Shield of
08.2018 - 03.2023

RN II, Commercial Risk Adjustment Management; Exchange Population

Horizon Blue Cross & Blue Shield of NJ
09.2015 - 08.2016

RN I, Primary Nurse Case Management

Horizon Blue Cross & Blue Shield of NJ
10.2013 - 09.2015

Staff Registered Nurse, Charge Nurse

Chilton Memorial Hospital
04.2000 - 09.2015

Associate Degree - Nursing

Felician University

Bachelors of Science - Nursing

Saint Peter's University

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