Senior Medical Underwriter

at Highmark Health in Boise, Idaho, United States

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 groups 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 physicians 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.

+ 2. Risk Analysis of Ongoing and Renewal Members / Groups

+ Provides current and predictive reporting regarding high and potential high medical costs for members/groups.

+ Gathers c