Health Plans:
Organization Chart

A Health Plan, or Health Insurance, company is made up of several smaller groups and functions, which work together to provide the best possible care and customer service to policyholders and plan members. Listed below are the common functions (and some related job titles) that comprise a typical Health Insurance provider.

Channel Management,  Claims Processing,  Medical Document & Data Management,  Member Services,  Network Development,  Network Management,  Provider Contracting & Licensing,  Underwriting & Actuarial

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Channel Management

The channel management group works with external resources to assist in the sale and distribution of their health plan products and also ensures that carriers meet compliance and regulatory mandates set forth by the Patient Protection and Affordable Care Act of 2010 (PPACA). In an effort to reduce reliance on agent-only sales (and drive down administrative and commission expense), health plans are turning to alternative distribution channels and strategies such as remote telesales, direct-to-consumer sales, direct-to-company sales, online sales and sales enablement.

Common Job Titles: Manager of Channel Solutions, Healthcare Channel Specialist, Patient Channel Marketing Manager, Channel Sales Director/Manager

Claims Processing

The claims processing group works closely with plan members (customers) to research and resolve health insurance claims and pay providers in a timely manner following an incident or physician visit. The group works with in-network providers and customers to determine eligibility, billing amounts, available levels of care (based on plan benefits) and appropriate provider compensation.

Common Job Titles: Tax Manager, International Tax Manager, Sales Tax Manager, Property Tax Manager

Medical Document & Data Management

The health care document and data management function is responsible for storing and organizing data from patients, medical institutions, pharmaceutical companies and back office payment systems. As health care providers and medical institutions move away from paper records, having systems and processes that can interface with Electronic Health Records (EHR), medical billing standards and disease/health problem classifications (ICD-10) is becoming increasingly essential. Health plan providers leverage medical data related to demographics, patient medical history and medication usage to drive their network development efforts, implement benefits design strategies and improve population health.

Common Job Titles: Health Care Data Administrator, Health Care Data Analyst, Health Care Data Integration Architect

Member Services

The member services function is responsible for ensuring that health plan customers (“members”) are informed of policy benefits, premiums, network details and personal healthcare management. They field questions (through a call center, in person or via the internet) from members and supply answers and benefits documentation in a timely manner, whenever possible.

Common Job Titles: Member Services Representative, Customer Service Representative, Provider Advocate, Client Service Specialist

Network Development

The network development function assesses markets and assembles a network of health care providers with the appropriate care (primary care, specialists, academic , etc.) and product mixes (HMO, PPO, Medicare, etc.) to fit the demographics of their target market. They work to determine provider alignments and meet regulatory requirements for network adequacy. The network development group also assembles recruitment packages and other materials for potential providers to educate them on the details of the health plan.

Common Job Titles: Manager of Network Development & Contracting, Provider Contracting Specialist, Manager of Network Development

Network Management

The network management function is responsible for the maintenance of the health plan’s contingent of healthcare professionals (physicians, care takers, pharmacies, etc.). The function works to renew and audit provider contracts, negotiates provider compensation levels, manages relationships with providers and educates them on health plan details. The network management function is also tasked with ensuring that all in-network healthcare providers meet the company’s standards of healthcare service and qualifications.

Common Job Titles: Physician/Hospital/Ancillary Provider Representative, Credentialing Representative, Provider Administration Representative, Provider Network Developer, Provider Network Analyst

Provider Contracting & Licensing

The provider contracting and licensing group manages contractual agreements with the health plan's network of preferred providers (PPNs) and other physicians and educates them on payment procedures (payer time frame requirements), plan product offerings (Commercial PPOs, etc.), contract benefits (promotion of a physician's practice, etc.) and contract termination terms.

Common Job Titles: Provider Contracting Specialist, Provider Relations Manager, Provider Contracting Executive, Provider Contract Management Specialist

Underwriting & Actuarial

The underwriting and actuarial functions are tasked with performing complex mathematical modeling and statistical analysis to aid in decision making regarding the mitigation of risk related to health insurance premiums and benefits design. Underwriters examine customer insurance applications to evaluate the risk associated with each customer to assign the correct level of coverage (premiums, benefits, deductibles, etc.). Actuaries assess and assign risk to certain segments of health plan members based on medical history, demographic data, family history and several other factors.

Common Job Titles: Medical Actuary, Actuarial, Actuarial Analyst, Actuarial Technician, Actuarial Consultant, Underwriter (Levels I-III), Underwriting Analyst/Specialist