About the role

The Senior Medical Underwriter is a highly experienced, results-driven professional responsible for evaluating, pricing, and managing a book of business. The Senior Medical Underwriter serves as a subject matter expert and mentor within the Underwriting team, modeling professionalism, productivity, clinical expertise, and leadership in every aspect of their work.

What you'll do

Underwriting & Risk Evaluation
• Manage a book of business, achieving profitable risk selection that supports Optimyl's overall business targets and assigned volume goals.
• Confirm group eligibility and employee eligibility at the time of new business quotes and mid-year additions.
• Analyze individual member risk and aggregate risk at the total group level, applying sound clinical risk management judgment and established underwriting principles.
• Calculate rates and evaluate financial arrangements including networks, plan designs, and carve-outs; interpret pricing policy and adapt to unique or complex situations.
• Apply corporate risk management policies appropriately and recommend pricing adaptations within established guidelines to accommodate client-specific circumstances.
• Utilize Optimyl's business rules related to participation, product availability, and eligibility, ensuring consistent and accurate application across all accounts.
• Leverage strong knowledge of medical diagnoses, case management background, medications, FDA-approved treatment plans and duration associated with conditions, as well as claims associated that pose risk to plan, to assess risk accurately and make informed underwriting decisions.
• Interpret clinical data, including claims data, lab results, and prescription history-and apply underwriting guidelines consistently and independently based on that analysis.
• Accurately differentiate acute and resolved conditions from chronic conditions requiring ongoing treatment and ongoing claim risk to plan.
• Identify questionable claim patterns of renewal clients; evaluate competitor claims experience for prospective clients and develop recommendations to account for these situations.

Productivity & Quality
• Complete medical review for quotes and review of Underwriter's work in accordance with established production, accuracy, and timeliness standards.
• Utilize various systems, tools, and resources to obtain necessary data and accurately complete and track all assigned work within established underwriting guidelines.
• Adapt effectively to changing priorities as quotes arrive from different production sources and as new requirements emerge, maintaining due diligence.
• Work independently to manage workload, utilize established SOPs and SharePoint resources, prioritize tasks, and meet deadlines without requiring close supervision.
• Solve problems independently using established resources and apply a solution-oriented approach to workflow challenges, escalating only when appropriate.

Communication & Coordination
• Serve as a subject matter expert to Sales on diagnoses, disease processes, and FDA-approved treatment plans, referencing reputable resources.
• Maintain a positive, professional demeanor in all interactions, fostering a collaborative and respectful team environment.
• Maintain an innovative growth mindset, growing with the company, as well as a willingness to pivot to meet business goals and demands.
• Demonstrate a clear understanding of company goals and partner with management and Sales to actively promote and support those objectives through sound underwriting decisions.

Leadership & Mentorship
• Demonstrate leadership through example; modeling high standards of work quality, professionalism, accountability, and a positive attitude.
• Mentor and guide Underwriters, providing technical assistance, constructive feedback, and support for professional growth.
• As assigned, assume primary responsibility for the maintenance and improvement of departmental tools, processes, and documentation.
• Support internal initiatives including underwriting policy development, training programs, corporate compliance efforts, and product development as needed.
• Proactively provide recommendations and input on new and existing training materials and Policies & Procedures, contributing expertise to strengthen the overall quality and consistency of the Underwriting function.

Ideal profile

Required
• Minimum of three (3) to five (5) years of Medical Underwriting experience; experience with self-funded, level-funded, and stop-loss preferred.
• Strong knowledge of medical diagnoses, prescription medications, FDA-approved treatment regimens, coordination of benefits, and claims associated with FDA-approved treatment durations for conditions and Rx.
• Proven ability to work independently, manage competing priorities, and deliver high-quality work product with minimal direction.
• Demonstrated solution-oriented approach to problem-solving, with the ability to apply established resources and underwriting principles to complex situations.
• Excellent written and verbal communication skills, with the ability to clearly articulate recommendations and rationale to internal stakeholders with an emphasis on tact.
• High level of productivity and accountability, with a consistent record of meeting or exceeding production and timeliness standards.

Preferred
• Prior experience mentoring or training health insurance underwriting staff.
• Minimum of five (5) years of clinical experience as a health care case manager, clinical credentials, and/ or licensure such as: Registered Nurse, Licensed Practical Nurse, Medical Assistant, or equivalent clinical practice experience.

Benefits include:

• Competitive compensation
• Comprehensive health coverage (medical, dental, vision)
• Employer-paid life insurance and disability coverage
• 401(k) retirement plan with employer match
• Generous paid time off and company holidays

We support growth through hands-on learning, exposure to new challenges, and opportunities to expand responsibilities as the company evolves.

The pay range for this role is:

85,000 - 90,000 USD per year (Remote (United States))