Examiner – Market Conduct Examinations

Examination Resources, LLC; United States; On-site; USD 70,000 - 90,000; Full time

Job summary

A woman-owned small business is seeking an individual to analyze health insurance product submissions to ensure compliance with federal and state laws. The ideal candidate will have exceptional communication skills, proficiency in Microsoft Office, and at least two years of experience in health insurance policy review. This role is remote and requires the ability to adapt to changing priorities and work independently. Knowledge of the Affordable Care Act is essential.

Qualifications

• Minimum of 2 years of experience drafting or reviewing health insurance policy forms.
• Two years of work experience in a healthcare-related field.

Responsibilities

• Analyze health insurance product submissions for compliance.
• Deliver objections and recommendations on health insurance contracts.
• Maintain up-to-date understanding of health insurance policy changes.
• Participate in quality peer reviews.

Skills

Knowledge of the Affordable Care Act

Clinical aspects of health care delivery

Exceptional written and oral communication

Proficient in Microsoft Office

Ability to work independently

Adaptability to changing priorities

Education

MCM designation issued by Insurance Regulatory Examiners Society

Tools

Microsoft Office (Word, Excel, PowerPoint, Teams, Outlook)

Adobe Acrobat PDF

Job description

Examination Resources, LLC (ER), a woman-owned small business, offers high-level expertise and experience in conducting professional services regarding all aspects of insurance company operations exclusively for insurance regulators. ER's philosophy in management emphasizes quality, efficiency and first-rate representation. ER has continued to grow through its dedication, excellent work and outstanding performance as a representative of its clients.

SUMMARY OF ROLE

ESSENTIAL RESPONSIBILITIES

Reasonable accommodation may be made for individuals with medical limitations or disabilities to perform the Essential Responsibilities.

• Analyze health insurance product submissions (i.e., policies, riders, amendments, endorsements, evidence of coverage, Summary of Benefits and Coverages, solicitations, compliance review tools, etc.) to ensure compliance with applicable federal and state laws.
• Deliver appropriate objections and recommendations regarding compliance of health insurance contract provisions at very high standards.
• Complete the work with high quality and within defined timelines.
• Actively participate in peer review as part of the quality program.
• Maintain up-to-date understanding of relevant health insurance policy changes

KNOWLEDGE, SKILLS & ABILITIES

• Knowledge of the Affordable Care Act and the Consolidation Appropriations Act, and their application to health insurance policies
• Knowledge/understanding of the clinical aspects of health care delivery in the U.S., such as billing/coding, pharmacy formularies, claims processing
• 2 years’ experience drafting or reviewing health insurance policy forms
• Ability to interpret regulations and make decisions based on those regulations

MINIMUM QUALIFICATIONS

• Exceptional written and oral communication.
• Proficient in Microsoft Office (Word, Excel, PowerPoint, Teams, and Outlook) and Adobe Acrobat PDF.
• Ability to work independently and with a team in a remote environment.
• Ability to adapt to changing priorities, self‑motivated and knowledge of health insurance laws and regulations, with particular emphasis in the Affordable Care Act (ACA).
• MCM designation issued by Insurance Regulatory Examiners Society (IRES), or ability to obtain designation within 90 days of initial engagement.
• Two years of work experience in a healthcare-related field, or other directly related experience.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made for individuals with medical limitations or disabilities to perform the essential functions.

• Sitting for long periods of time.
• Ability to see and hear well (naturally or with correction).
• Able to work in a constant state of alertness and safe manner.

WORK ENVIRONMENT

The work environment is characteristic of a remote office setting, where employees perform their duties from home or another location outside the traditional workplace, utilizing technology to communicate and collaborate.