Address
SalaryAnalista de Reaseguro y Manejode Riesgo
Regular
Exento
Responsible for analyzing and preparing the claims reports submitted to Reinsurance companies to notify the cases that apply for reimbursement of the reinsured business accounts. Audits the information of the implementations and the signed cost sheets of the groups sold and renewed and informs the corresponding area of any discrepancies found in the documents to correct them.
ESSENTIAL FUNCTIONS:
- Audits the MHS, SIBEL, and PAS systems, using the cost sheets duly signed by the client of the accounts sold and renewed, related to benefits, group name, group number, rates, co-payments, and deductibles, vision coverage, dental design, pharmacy coverage, medical coverage, among others, and if discrepancies are found, the corresponding area is informed for duly amendment. Complete the Audit Memo for each Fully Insured and Cost-Plus account.
- Validate that the fully insured group renewal documents are complete and up to date.
- Gather and analyze utilization data of the deductible of the Specific Stop Loss of the reinsurance of each insured of the Fully Insured commercial portfolio and the Cost-Plus accounts with reinsurance and generate the reports according to the types of contracts and the coverages considered for the purpose to determine and/or request reimbursement for cases that exceed the corresponding deductible.
- Validate and prepare data for analysis, including eliminating errors, identifying outliers, and transforming data into a format that can be analyzed. Must ensure accuracy in data analysis and recognize anomalies or errors in data.
- Generates and maintains the report of submitted cases exceeding the deductible of Specific Stop Loss to monitor the submitted and received reimbursements and the reinsurance pending balance.
- Collaborating with other departments or teams involves understanding their needs and providing them with relevant data insights. Gather, analyze, and submit Group Insurance Policies, additional claims reports, and medical and clinical documents as requested by the reinsurer. Evaluated by the corresponding departments for further action.
- Generate Shock Claims Report to request from the Department of Clinical Affairs and/or Pharmacy, and submit to reinsurance, the prognosis of the cases in the evaluation process to request reimbursement for those cases that qualify.
- Participates in gathering the necessary information for the renewal of the Reinsurance of the MCS Commercial Portfolio.
- Updates high-impact case information, premium history, and claims paid.
- Monitors the reimbursement of the cases submitted to reinsurance and works the reimbursement report, as required.
- Keeping effective channel communication with the reinsurer regarding explaining the reports.
- Report to the Information Technology Department when the PBM (Pharmacy Data Management) data report of Cost-Plus Account is not uploaded to Power MHS.
- Recognizes the ethical implications of data usage, storage, and analysis, especially in terms of privacy and security
MINIMUM QUALIFICATIONS:
Education and Experience: Bachelor’s degree in Business Administration with a major in Finance, Accounting, Mathematics, Natural Sciences, or related areas. At least three (3) years of experience in Eligibility, Underwriting, Insurance, and Reinsurance in the Health and Group Life Insurance Industry.
“Proven experience may be replaced by previously established requirements.”
Other: Proficiency in Excel and Access. Ability to query databases using systems for extracting data, like SQL, Hyperion, Tableau, Power BI, among others. Basic knowledge of reinsurance practices and procedures.
Languages:
Spanish – Intermediate (comprehensive, writing and verbal)
English – Intermediate (comprehensive, writing and verbal)
“Somos un patrono con igualdad de oportunidad en el empleo y tomamos Acción Afirmativa para reclutar a Mujeres, Minorías, Veteranos Protegidos y Personas con Impedimento”
