Medical Underwriting Manager

Tokio Marine HCC • Wakefield, MA

1d • $126,000 - $190,000 • Onsite

About The Position

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
• Registered Nurse (RN) designation required
• 6 years of 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 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.

Benefits

• Comprehensive medical, vision, and dental coverage, with eligibility beginning on your first day of employment
• Basic life and disability insurance
• 401(k) plan with 6% company match
• 20 days of PTO, two floating holidays, approximately 11 paid holidays, and volunteer time off
• Paid parental leave
• Access to our award-winning wellness program, including mental health services, fitness network membership, and a complimentary Headspace subscription
• Student loan matching program
• Employee discount program

What This Job Offers

• Job Type: Full-time
• Career Level: Manager