Senior Medical Underwriter

Let’s change healthcare together! At Optimyl Benefits, we provide accessible, high-quality, and easy-to-use healthcare plans for small employers. We partner closely with the broker community to help employers offer competitive benefits without unnecessary complexity. 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. Why Work at Optimyl? At Optimyl Benefits, we’re focused on simplifying healthcare for small employers and building a workplace where people can do meaningful work and continue to grow. 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.