Job ID: J109087
Location: Wilkes-Barre, PA, United States
Full/Part Time: Full time
Job Type: Regular
I. GENERAL OVERVIEW:
The Medical Underwriter 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.
II. ESSENTIAL RESPONSIBILITIES:
1. 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.
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 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.
3. Fulfills Highmark’s mission to provide and maintain affordable products, by performing ongoing review of the medical underwriting guidelines and departmental procedures. Interfaces with physicians, regulatory / compliance staff, privacy and legal advisors to resolve medical risk issues while promoting efficiency, consumerism and customer service.
4. Quality and Production
• 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.
5. Risk and Compliance
Understands and complies with all Regulations in regards to security and confidentiality of Protected Health Information, including HIPAA, GINA and PPACA.
6. Communicates effectively while interacting with all internal and external customers. Ability to communicate with clinicians and non-clinicians regarding medical condition findings.
7. Other duties as assigned or requested.
• High School Diploma/GED
• 5-10 years of relevant, progressive experience in the area of specialization
• Current RN licensure in state(s) of practice
• Additional relevant knowledge, skills or experience Master’s education level in relevant field
• Professional health claim coding/ billing certification
• 3 years of clinical practice
• Bachelor’s Degree or 8-10 years of clinical or underwriting experience
Knowledge, Skills and Abilities
• Communicate effectively. This position requires skilled and knowledgeable interaction with various internal departments and external stakeholders.
• Demonstrate the ability to use applicable computer systems, electronic tools and applications.
• Demonstrate the ability to be responsible for projects across a continuum from routine to highly complex.
• Engage in teams/workgroups and contribute to successful accomplishment of departmental or team goals or output.
• Demonstrate ethical business practices with adherence to all privacy and confidentiality policies and regulations.
IV. SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees? No
V. WORK ENVIRONMENT
Is Travel Required? Yes
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 their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
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