Senior Medical Underwriting Nurse Manager

Overview

The Sr. Medical Underwriting Nurse Manager is responsible for leading clinical risk strategy and underwriting excellence within the Small Group market, reporting to the VP of Small Group Underwriting. This role combines advanced clinical expertise with underwriting leadership to drive profitable risk selection, guide pricing strategy, and support renewal and new business growth. The position partners cross-functionally with Actuarial, Sales, IT, Compliance, and Underwriting to ensure sound risk management, operational efficiency, and achievement of key business metrics.

Duties

• Contributes to the development of underwriting guidelines for clinical underwriting risk management
• Guides underwriting strategy in collaboration with VP of Small Group Underwriting and internal stakeholders for targeted profitable risk selection.
• Provides expert clinical consulting on underwriting risk initiatives in collaboration with Actuarial Partners, Sales, IT, Underwriters, and Compliance.
• Managers direct reports and relationships with key stakeholders as delegated with mentorship and clinical consultations as needed.
• Help formulate and execute strategy of how to hit or exceed key target metrics such as loss ratio, underwriting expense, close ratio, and underwriting turnaround times.
• Develop and manage relationships with internal business partners, including actuarial, sales, IT, and compliance
• Responsible for a book of business of renewing accounts and writing new business at profitable levels to help Optimyl achieve overall business targets or assigned volume of new applications or RFPs.
• Uses various systems, tools, and resources to obtain necessary data and accurately complete and track assigned work.
• Evaluate the eligibility of groups and the participating employees at the time of a new business quote; evaluate the eligibility of mid-year participating employee additions.
• Calculate rates, evaluate different financial arrangements (e.g., networks, plan designs, carveouts), interpret pricing policy, and adapt to unusual situations.
• Identifies questionable claim patterns of renewal clients and evaluates competitors’ claims experience for prospective clients, and develops recommendations to account for these situations.
• Applies corporate risk management policies and adjusts for unusual situations that may not have been considered in the standard pricing formula. Identifies when clients do not comply with corporate risk management policies, disclosure rules, or conditions/criteria for enrollment.
• Enforce Optimyl's business rules (participation, product availability, etc.) Recommends appropriate adaptation of pricing within the appropriate policy or guideline to accommodate each client-specific situation.
• Analyzes individual member risk and aggregate to the total group. Supports other internal initiatives which may include but is not limited to underwriting policies and procedures, training, fraud detection, corporate compliance, and product development efforts. Completes renewals, prospective quotes, and review of lower-level analyst (Underwriting Analyst) work in accordance with production and timeliness standards.
• Adapts to changing priorities as quotes come in from different markets and adapt to new priorities and requirements.
• Communicates recommendations of policy adaptation to accommodate client-specific situations or changes to overall policy supported by a clear rationale or management principles.
• Serve as a clinical SME to sales and account management. Influences Sales team and external audiences toward appropriate risk solutions. Influences Sales team toward the appropriate pricing and structure of each quote. When necessary, influences other market partners, e.g. brokers.
• Guides, assists, and provides technical assistance to lower-level analysts. As assigned, assume primary support for maintenance of departmental tools and processes. As assigned, represent departmental perspectives and needs on system development and process improvement teams.

Qualifications:

Registered Nurse, BSN

5 Years of Medical Underwriting Experience in Stop Loss, Self-Insured, or Level Funded market

Advanced clinical knowledge of common and high-risk diagnoses, associated FDA-approved treatment plans and durations, Specialty Rx, emerging risk, and case management.

Expert knowledge of claims for common and high-risk diagnoses, treatment plans, and specialty Rx.

Preferred Qualifications:

MSN/ MBA

Small Group Health Insurance Medical Underwriting Experience