Job Description

Company :

Highmark Inc.

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.

• 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.

QUALIFICATIONS:

Minimum

• High School Diploma/GED
• 5-10 years of relevant, progressive experience in the area of specialization
• Current RN licensure in state(s) of practice

Preferred

• 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.​

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.

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For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

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