The functions listed below make up the organizational structure of a typical health insurance, or health plan provider, company.
The business development function performs the marketing and sales of health plans. This function is responsible for developing new business opportunities and selling their clients’ exclusive health plans to consumers. They are also largely responsible for the maintenance and development of existing client base, longterm customer relationship management, and channel support.
Common Job Titles: Sales, Sales Support, Channel Support, Sales Representative
Network Development & Management
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. Accordingly, 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, negotiate provider compensation levels, manage relationships with providers and educate them on health plan details.
Common Job Titles: Manager of Network Development & Contracting, Provider Contracting Specialist, Network Manager, Network Specialist
Actuarial & Underwriting
The actuarial function is 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. Actuaries assess and assign risk to certain segments of health plan members based on medical history, demographic data, family history and several other factors. The medical underwriting function is responsible for assessing an applicant for health insurance coverage. Medical insurance providers are permitted to ask questions about an applicant's medical history. The applicant's health information could be used for deciding whether to offer or deny coverage and what premium policy rate will be used. Health insurance underwriters weigh the probable health risks of their applicants against the potential costs of providing coverage.
Common Job Titles: Medical Actuary, Actuarial, Actuarial Analyst, Actuarial Technician, Actuarial Consultant, Medical Case Manager
The policyholder service function is responsible for the reception of incoming calls and requests from current policyholders to assist with account updates, payments, insurance policy inquiries, account modifications, or status updates. This function assists policyholders in understanding the policies they have and informs them of additional insurance products they can offer.
Common Job Titles: Chronic Disease Management Coach, Disease Management Nurse
The medical claims function is responsible for handling bills, for healthcare services, submitted by healthcare providers. These bills become medical claims to an insurance provider to process for payment. Carriers that process medical claims are comprised of federal, state, and third parties.
Common Job Titles: Medical Claims Processor, Medical Claims Auditor, Medical Claims Examiner
The prior authorization function is responsible for obtaining approval from a third-party insurer about the accuracy, suitability, and coverage of a service or medication. This allows a patient to know ahead of time whether or not a procedure, treatment, or service will be covered under their plan. They also decide whether or not patients will be approved for certain medications that have serious side effects, are highly regulated, and/or are incredibly costly.
Common Job Titles: Insurance Prior Authorization Specialist, Insurance Verification Specialist
Medical Billing & Coding
The medical coding function is responsible for interpreting medical reports written by doctors and other healthcare providers into simple, standard medical terms recognized by health insurance providers, for billing purposes. The accurate interpretation of medical reports is imperative in order to ensure the insurance company can quickly and efficiently understand and process received claims. The medical billing group works with insurance companies to collect money for medical services rendered. Medical codes that determine the level of service and diagnosis are used by both healthcare providers and insurance companies to ensure that the correct amount is billed. Several factors determine the billing amount and method; insurance policy type, copay amount, patient history and government regulations (HIPAA) all facto into the billing process. Many times, medical billing employees receive training and certifications to better understand the complex interactions between healthcare providers and insurance companies.
Common Job Titles: Medical Billing Clerk, Medical Billing Analyst, Medical Coder, Certified Medical Coder