Senior Medical Underwriter

Job Listing ID:

4487730

Job Title:

Senior Medical Underwriter Application Deadline:

Open Until Filled

Job Location:

Salem

Date Posted:

05/07/2026

Hours Worked Per Week:

Not Provided Shift:

Not Provided Duration of Job:

Either Full or Part Time, more than 6 months You may contact this employer directly. (Obtain the contact information to print or add to your jobs.)

Job Summary:

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 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. 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. 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. 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. Risk and Compliance ...

Job Classification:

Insurance Underwriters Access our statewide or regional occupation report for more information about wages, employment outlooks, skills, training programs, related occupations, and more. Compensation

Salary:

Not Provided Job Requirements

Experience Required:

 See Job Summary

Education Required:

None

Minimum Age:

N/A Gender:

N/A