Medical Underwriting Manager

Tokio Marine HCC

5d•Remote

About The Position

Tokio Marine HCC (TMHCC) brings 50 years of service to the specialty insurance industry, today offering over 100 products to commercial customers in 180 countries around the world. Organic growth and over 60 successful acquisitions have grown our 2022 Gross Written Premium (GWP) to $5 Billion. Our workforce has grown to 4,300 worldwide … big, but not so big that you cannot make a difference. Our Good Company values, including integrity, empowerment, and commitment to customer service, and a culture of innovation, communication, and collaboration make TMHCC a great place to work. TMHCC Stop Loss, a $2 Billion division within TMHCC, leads the way in providing medical stop loss insurance sold to employers. Medical Stop Loss provides an added layer of insurance protection to employers who choose to self-fund their health benefit plans. Self-funding can incur risks from catastrophic claims, and Medical Stop Loss insurance from Tokio Marine HCC is designed to protect employers from that risk. This role is remote Position Summary: Manages the Medical Underwriting department of the Regional Office. Manages the review process of Request for Proposal (RFP) and renewal data for high-dollar and complex diagnoses and estimates remaining costs for underwriting recommendation and quoting. Ensures medical underwriting recommendations align with company guidelines, regulatory compliance, and service standards. Drives team development, enhances workflow efficiency, and collaborates closely with underwriting, claims, sales, actuarial, and other leadership teams to support business growth

Requirements

4 Year / Bachelors Degree in Nursing, a related field, or the equivalent education and/or experience Required
Registered Nurse (RN) designation
6 Years Relevant and progressive clinical experience, preferably in stop-loss reinsurance, group health insurance, managed care, or related fields
3 years of leadership experience
Strong medical knowledge including International Classification of Diseases (ICD), Current Procedural Terminology (CPT), medical terminology, COBRA, and HIPAA
Strong understanding of operations of third-party administrators (TPAs) and managing general underwriters (MGUs)
Knowledge of Carrier and Reinsurer reporting and contractual requirements
Possess and have ability to apply broad knowledge of principles, practices, and procedures
Deep clinical knowledge across multiple specialties, including chronic conditions, complex case management, and high-cost claims
Excellent critical thinking, decision-making, and risk evaluation skills
Excellent written and verbal communications skills with an emphasis on confidentiality, tact, and diplomacy
Exceptional organizational skills with the ability to manage competing priorities and deadlines
Ability to lead and inspire a team toward achieving department and organizational goals
Knowledgeable of industry changes, legal updates, and technical developments related to applicable area of the Company's business to proactively respond to changing business environment
Advanced proficiency and experience using Microsoft Office package (Excel, Access, PowerPoint, Word)

Responsibilities

Review issues forwarded from the Medical Underwriting Nurses and Underwriters that include complex diagnoses and require an estimate of ongoing costs.
Oversee clinical assessments of medical records, questionnaires, and claims history to identify potential risks and recommend appropriate underwriting actions (such as exclusions, contract restrictions, etc.).
Serve as subject matter expert for complex or escalated cases and reviews.
Ensure thorough and timely documentation of medical underwriting decisions and rationale.
Collaborate with Underwriting team to craft custom risk recommendations based on clinical insight and policy guidelines.
Provide support for Underwriting team; this includes, but is not limited to, assessing the severity of on-going claims, adjusting reserves for accuracy, and evaluating new referrals.
Act as a resource for the Sales and Marketing teams by providing clinical underwriting expertise and insights into risks, loss trends, and catastrophic claims.
Represent the MUN team in internal meetings and cross-functional projects.
Lead, coach, and develop a team of Medical Underwriting Nurses to maintain high performance and professional growth.
Assign and prioritize workload based on case complexity, timelines, and business needs.
Conduct regular performance reviews, provide mentorship, and establish individual and team development and professional goals.
Educate Medical Underwriting Nurses and Underwriters on how to recognize specific diagnoses and severe types of diagnoses to ensure these are identified and properly quoted during the underwriting process.
Develop, implement, and refine medical underwriting workflows, tools, and best practices to improve efficiency and quality.
Analyze trends in underwriting decisions and recommend guidelines updates or training enhancements.
Gather relevant information on an on-going basis to determine the plan's effectiveness and measure cost benefits and set accurate reserves.
Educate the third-party administrators (TPAs) and vendors regarding the Medical Underwriting Program, as needed.
Complete projects and other relevant duties as assigned by supervisor.
Develop work plans, establish timelines, and set goals for assigned work unit.
Assign resources as needed.
Meet commitments on deadlines.
Communicate team or group results to management and make appropriate recommendations.
Prepare written and verbal presentations to convey information.
Drive improvement in existing business processes and assist in the identification and implementation of new processes.
Assist in development and is accountable for budget for work unit
Work within financial objectives set by management.
Comply with all corporate policies and procedures.
Identify control objectives for designated function and implement cost-effective controls designed to meet those objectives.
Test controls to determine if they are performing as intended.
Has full HR responsibility for direct reports including making hiring decisions, training, coordinating work, establishing standards, reviewing work, conducting performance appraisals, and providing coaching or counseling.