Job Title: UNDERWRITER, MEDICAL SENIOR
Location: OWINGS MILLSCareer Band: BAND B
Job ID #: 8084
SUMMARY: The Senior Medical Underwriter provides support to the large group underwriting teams as well as the stop loss underwriters by performing clinical and medical analysis of large ongoing or catastrophic claims and providing them written summaries of future risk assessment. The incumbent is responsible for creating and applying medical underwriting guidelines and working with the departmental trainer to educate the underwriting teams. The incumbent understands the difference between clinical prognosis and future financial risk. The incumbent helps build and maintain models to help analyze CareFirst results, and develops and prepares pertinent reports. The incumbent prepares, and may do presentations.
PRINCIPAL ACCOUNTABILITIES: Under the general supervision of the Director, Underwriting Strategy, Reporting and Financial Settlements, and with minimal direction, the incumbent’s principal accountabilities include, but are not limited to, the following:
--Gathers and prepares clinical and medical analysis based on information from historical claims utilization data and other sources. Analyzes and interprets medical records and completes accurate medical summaries.
• Supports both large group underwriting teams and ASO/Stop Loss team by estimating future costs associated with large, ongoing or catastrophic claims and providing written estimates of ongoing risk.
• Recommends appropriate lasers for stop loss for potential catastrophic claims.
--Creates, applies, and maintains underwriting guidelines for use by financial underwriters.
• Provides technical subject matter expertise to the underwriting team. Serves as a clinical resource for the underwriting team regarding unusual/complex medical conditions and treatments/claims cost.
--Develops/prepares reports and assists in the development of new/revised policies and guidelines based on utilization and clinical trends.
• Prepares and may do presentations. Participates in cross-functional teams to develop new/enhanced systems/processes/programs/ policies to support business needs.
• Assists and provides clinical and medical analysis on statistical research, studies and product development initiatives as needed. Works with reports analyst to build and maintain models to assist in the economic analysis of market alternatives. Analyzes health benefit plan characteristics and assesses risks as to frequency and potential severity of loss of clients.
QUALIFICATIONS REQUIREMENTS:
Required:
• Registered nurse or LPN with 5+ years of clinical experience or 5+ years medical underwriting experience.
• 3+ years experience in an insurance, stop loss, TPA or reinsurance claim environment.
Preferred:
• Familiarity with CareFirst product portfolio, and CareFirst enrollment, claims and reporting systems desired, but not required.
• Strong clinical knowledge base with regard to standard treatment plans by diagnosis for adult, pediatric and neonatal patients.
ABILITIES/SKILLS:
• Must be able to make independent, educated decisions based on the facts presented.
• Self-starter who will take initiative. Ability to accept responsibility and accountability.
• Effective team player. Able to develop effective relationships with individuals at all levels in a fast-paced, changing environment.
• Excellent written and oral communication skills. Must establish him/herself as the subject matter expert.
• High level of proficiency with Microsoft software and other computer applications experience (for example claims systems, case management systems, or medical records).
• Basic familiarity with applicable federal and state laws and regulations such as HIPAA and consumer privacy.
• Ability to evaluate and research current diagnostic and treatment information.
• Basic understanding of medical terminology, human biology, anatomy and physiology.
• Must be able to effectively work in a fast paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from both internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including those who may be demanding or otherwise challenging.
• Strong organizational skills, with attention to detail.
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
PHYSICAL DEMANDS:
The physical demands described here are representative of those that must be met by an employee to perform the essential duties and responsibilities of the position successfully. Requirements may be modified to accommodate individuals with disabilities.
The employee is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The employee must frequently talk and hear. Weights of up to 25 pounds are occasionally lifted. Travel to other CF sites for training may be required.
Department: Administration of Underwriting Strategy, Reporting and Financial Settlement
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of theCompany to provide equal employment opportunities to allqualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Must be eligible to work in the U.S. without Sponsorship
Please apply before: January 31, 2016
Actual salary will be based on relevant job experience and work history.