Contract position with Aetna's Small Group AFA Underwriting Department Performs underwriting analysis and risk assessment for new and/or renewal of large group contracts and accountings.Assigned cases/book of business include single product types, funding arrangements and/or rating methodologies and progresses to multiple types, arrangements and methodologies with experience and skill development.Prepares and delivers routine to moderately complex new business quotes and/or existing business renewals and/or accountings.Independently reviews work for accuracy. Works with mentor/manager to recommend pricing and/or accounting balance alternatives based on financial analysis, underwriting principals, and business strategy.Assists sales personnel in explaining rate/fee, accounting balance development and communicating underwriting policyProduces timely and accurate customer specific documents, deliverables and accounting related information.Conducts audits on premiums, fees and claim wires to ensure all receivables are accurate and accounted for.Tracks customer allowances or MBE/WBE goals using compliance guidelines.

• Assists in targeting members/providers/encounters for chart review• Assists in analyzing patterns and trends to identify opportunities to improve HCC documentation and coding• Based on identification of documentation/coding trends and opportunities, assists with the development of provider education materials • Maintains a chart review and audit plan for identifying, acquiring, and reviewing medical records• Completes chart reviews or audits for retrospective, prospective and audit projects assigned• Performs quality reviews on documentation and coding to ensure compliance with ICD coding guidelines and guidance• Reviews, implements, and maintains documentation consistent with HHS and other government regulations, company goals and policies• Relays data corrections/code adjustments via the established processes to ensure accurate and timely Edge Server updates• During chart reviews, queries physicians regarding missing, unclear, or conflicting medical record documentation by requesting and obtaining additional documentation within the medical record when needed• Assists with periodic risk adjustment workgroups, especially when HHS changes the risk adjustment model and other regulatory guidance, coding guidelines, etc. • Collaborates with other members of the team, and other departments including Medical Management, Claims, Compliance, and Provider Relations to design, implement, and monitor the effectiveness of chart review and auditing processes• Participates in continuing education activities to improve knowledge of job performance or to maintain credentials • Employs project management techniques to ensure that projects are completed on time, on budget, and with high quality results• Responsible for organizing assigned work, managing the work to completion, and managing relationships required to accomplish the work

Responsible for review and analysis of risks posed by applicants requesting small group and individual health coverage and, when appropriate, development of an offer of coverage to the applicant. Position has the ability to issue coverage with an unlimited lifetime maximum. Develops offers of coverage that are equitable to the customer, deliverable by the agent and profitable to the company. Determines the degree of morbidity risk, using company medical guidelines and established precedents and practices. Using solid risk assessment principles, exercises independent judgment, deviating from established procedures and practices if the decision meets the Underwriting area’s established risk management philosophy. Incorporates strong understanding of medical terminology, contract law, company products and benefits, with risk appraisal.• Responsible for underwriting new business small group and individual applications for all medically underwritten products. Investigates health history appropriately and evaluates medical information and non-medical (contractual) information to arrive at the proper decision.• Analyze small group and individual applications, claims data, prescription drug data, medical records, medical exams and laboratory data/or information from other sources to properly evaluate the risk. • Make quality underwriting decisions, based on AvMed underwriting guidelines. Documents these decisions appropriately.• Ensures timely, accurate and consistent review of underwriting applications applying underwriting guidelines.• Meet productivity goals and manage pending application volumes.• Review requests for reconsideration of adverse underwriting decisions.• Recognize and observe all company and departmental policies and procedures.• Over five years’ experience working in the Siebel system environment (End user, User Acceptance Training, and Gap Analysis)• Comply with company policies and guidelines to maintain current workload

•Responsible for reviewing, gathering data and assessing risk against established underwriting guidelines, telephone interviews, prescription and claims histories.•Determine insurability on standard risk or with benefit and/or premium modifications.•Determine if declination of risk is appropriate on all prospective applicants.•Research and develop written responses to phone or written agent appeals as appropriate.•Focused on medical and financial conditions and other standard factors that can potentially affect morbidity of the health contract.*Contact outside sources via telephone or written requests for additional information to make appropriate medical underwriting decisions.

• Responsible for day to day operations of a large home medical equipment company.• Research all claim denials to full resolution with maximum reimbursement.•Coordinated all insurance reviews for filed claims.•Coordinate billing of all claims for all payors.•Effectively reduced accounts receivable for all third party payors.•Experienced in marketing products to hospitals.

•Resolved complex and unusual accounts with insurance review and appeal departments, attorneys, physicians, and patients.•Compiled special reports related to trends for management.•Researched patient charts for medical documentation, work orders, doctors orders and any other attachments required to bill via a claim or private pay.

•Coordinated and assigned work to assistant underwriters/support staff to best utilize the staff in minimizing cycle time.•Monitored on a daily basis the status of application inventory, planning work activities to ensure the most expeditious processing of applications.