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Job Description
Job Description:
Lead Medical Underwriter - Third‑Party Administrator (TPA) Position Overview The Lead Medical Underwriter is responsible for overseeing all medical underwriting activities within the organization, ensuring accurate risk assessment, financial modeling, and pricing for self‑funded employer groups and stop‑loss programs administered by the TPA. This role provides strategic underwriting leadership, supports business development efforts, mentors junior underwriters, and collaborates cross‑functionally with actuarial, sales, operations, and clinical teams to drive profitable growth. Key Responsibilities Underwriting Leadership & Risk Assessment Lead the evaluation of medical risk for new and renewing self‑funded employer groups, stop‑loss policies, and specialized health plans. Analyze historical claims data, high‑cost claimant reports, utilization patterns, and demographic factors to determine appropriate funding levels and rate actions. Develop and refine underwriting methodologies, guidelines, and pricing models to improve accuracy and competitiveness. Approve complex or high‑value underwriting cases within established authority limits. Financial Modeling & Pricing Build and review medical underwriting cost models, including expected claims projections, trend analysis, and catastrophic risk scenarios. Partner with actuarial teams to ensure alignment between underwriting assumptions and actuarial standards. Recommend plan design modifications, network strategies, and cost‑containment opportunities to improve group performance and pricing outcomes. Collaboration & Stakeholder Support Work closely with sales and client management teams to support new business proposals, renewals, and client presentations. Provide underwriting expertise during finalist meetings, broker discussions, and strategic client conversations. Collaborate with operations, claims, and clinical management to ensure holistic understanding of group performance and emerging risks. Team Leadership & Mentorship Supervise, mentor, and develop a team of underwriters, providing training on best practices, analytical skills, and underwriting tools. Conduct quality reviews of underwriting files to ensure accuracy, compliance, and consistency. Help define departmental KPIs, workflows, and service standards to support scalability and operational excellence. Compliance & Process Improvement Ensure adherence to regulatory requirements, internal controls, and TPA‑specific underwriting policies. Partner with IT and analytics teams to enhance underwriting systems, reporting capabilities, and workflow automation. Stay current on industry trends, medical cost drivers, stop‑loss market changes, and regulatory updates impacting underwriting. Required Qualifications Bachelor's degree in actuarial science, mathematics, health administration, business, or related field. 5-10+ years of medical underwriting experience , preferably within a TPA, carrier, or stop‑loss environment. Strong proficiency in analyzing large health claims datasets and financial models. Deep understanding of self‑funded plans, stop‑loss products, networks, and medical risk factors. Demonstrated leadership experience or mentorship of junior underwriters. Advanced Excel or analytics capability (pivot tables, modeling, VBA or similar preferred). Preferred Qualifications Experience working in a TPA environment or supporting self‑funded employer groups. Knowledge of cost‑containment strategies, medical management programs, and alternative funding arrangements. Familiarity with common underwriting platforms and healthcare analytics tools. Excellent communication and presentation skills, including broker‑facing experience. Key Competencies Analytical decision‑making Financial acumen Leadership and coaching Collaboration and communication Strategic problem‑solving Accuracy and attention to detail Ability to thrive in a fast‑paced environment
