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Senior Medical Underwriter
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Senior Medical Underwriter
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PA, Working at Home - Pennsylvania
Company :
Highmark Inc.
Job Description :
GENERAL OVERVIEW:
This job analyzes Individual and/or Group medical risk factors for new enrollment, yearly renewals, and amendments of group insurance contracts, or of self-funded plans in conformance with established underwriting policies, practices, and standards; analyzes associated policies, guidelines and market data to continuously improve risk management and gain appropriate enrollment or manage existing membership; analyzes data such as individual health, type of industry, characteristics of employee groups, or past claim experience to determine what benefits can be offered, which is a necessary component of the rates; prepares and presents first and second level medical underwriting appeals and applicable clinical records to physician advisors; and analyzes high medical cost claimants and prepares analytical reporting of current medical costs and predictive medical condition costs for purposes of assessing the group's renewal rates and impact on future potential medical claims. And if applicable, completes referral requests for case/care management or provider review. The incumbent must communicate effectively with various internal departments to manage risk through process/guideline improvements, referrals and project work.
ESSENTIAL RESPONSIBILITIES:
Risk Analysis of New and Pre-Screen opportunities
Applies medical review and medical underwriting principles to all New and Pre-Screen Individual, Small Group and Large Group Medically Underwritten product member applications, attending physician's statements, medical and drug claims history. Uses established guidelines and all information to make enrollment and rating decisions.
Apply corporate risk management policies and adjust for unusual situations that may not have been considered in the standard pricing formula.
Understands and effectively uses underwriting systems and tools. Actively participates in system enhancement and strategic planning to meet corporate goals.
Support other internal initiatives including but not limited to fraud detection, wellness/disease management, product development efforts.
Prepares and presents thorough clinical record reviews to first and if applicable, second level appeals to physician advisors.
Provides current and predictive reporting regarding high and potential high medical costs for members/groups.
Gathers claims history data from multiple sources, interprets and provides clinical judgment on diagnosis and estimates to the requestors regarding the impact on future potential claims.
For claimants over a specific threshold, or with aberrant medical claims or inconsistent information, performs analysis of all details for possible fraudulent / abuse referral to FIPR and / or Legal.
Participates in the department Quality Improvement Process by providing peer Inter-Reviewer Reliability [IRR] and Validity reviews to measure consistency with departmental goals.
Meets annual development, productivity and quality goals
Actively participates in bi-annual multi-disciplinary medical underwriting guideline review workgroup.
Understands and complies with all Regulations in regards to security and confidentiality of Protected Health Information, including HIPAA, GINA and PPACA.
QUALIFICATIONS:
Minimum
Preferred
Knowledge, Skills and Abilities
Language (Other than English):
None
Travel Requirement:
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Office-based
Teaches / trains others regularly
Occasionally
Travel regularly from the office to various work sites or from site-to-site
Rarely
Works primarily out-of-the office selling products/services (sales employees)
Never
Physical work site required
Yes
Lifting: up to 10 pounds
Constantly
Lifting: 10 to 25 pounds
Occasionally
Lifting: 25 to 50 pounds
Rarely
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Pay Range Minimum:
$27.02
Pay Range Maximum:
$41.85
Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below.
For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org
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Highmark Health is an independent licensee of the Blue Cross Blue Shield Association.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below.
For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org.
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Highmark provides millions of people with the security of quality health insurance
Our history of helping families and companies with their health insurance needs dates to the 1930s, when our predecessor companies were established to help Pennsylvania's residents pay for health care.
Highmark was created in 1996 by the consolidation of two Pennsylvania licensees of the Blue Cross and Blue Shield Association — Pennsylvania Blue Shield (now Highmark Blue Shield) and Blue Cross of Western Pennsylvania (now Highmark Blue Cross Blue Shield). We are now one of the largest health insurers in the United States.
Highmark's officers and board of directors set the company's strategic direction and corporate policies. They are guided by our mission, vision and values.