Health Insurance Company Organizational Structure Outline & Definitions
Health Insurance Organization Chart Template
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Health Insurance companies handle the delivery of health insurance plan benefits to customers and address any related customer issues. Health insurance can be provided on an individual or group (company or family coverage) basis. Services provided by health insurance companies to their plan members include physician identification and selection, family coverage, healthy living education and online account management, among other various forms of health-related assistance. Health insurance companies are also responsible for maintaining relationships with network healthcare providers (physicians, clinics, hospitals, etc.). Health insurance companies are often referred to as "Healthcare Payers" because they reimburse the cost of healthcare services to providers.
Common Health Insurance job titles: Chief Executive Officer (CEO), Chief Operating Officer (COO), Chief Medical Officer (CMO)
Health Plan Operations
Health Plan Operations refers to a set of essential administrative and support services for health plan members and providers. The Back Office is responsible for managing several activities such as claims processing, health plan member service/support (usually carried out within a Call Center), premium payment collection, actuarial, underwriting and application processing. Back Office staff members support the health insurance company's customers, healthcare providers within the company's provider network and internal employees.
Common Health Plan Operations job titles: Operations Specialist/Analyst, Customer Service Representative, Insurance Service Representative
Member Services
The Member Services 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 Member Services job titles: Member Services Representative, Customer Service Representative, Policyholder Services Specialist, Member Support Specialist
New Business Processing
The New Business Processing function is responsible for onboarding new insurance policyholders, or members. They collect the requisite information, pass that information to the appropriate underwriting and application processing staff members (based on application type, language requirements and product knowledge) to assess the appropriate premium and coverage levels, then communicate options and premium/deductible structures to the prospective policyholder.
Common New Business Processing job titles: Medical Insurance Application Processor, Medical Underwriter, Application Analyst
Application Processing
The Application Processing function is responsible for examining insurance applications from potential members, or policyholders, to ensure that they have all of the correct information required for underwriting and approval/denial. Applications come in through various channels - the internet, phone, insurance agencies. Applications may also be received in varying formats - paper, electronic, PDF, etc. Application Processing employees must be diligent in ensuring that applications are complete and accurate to reduce the number of customer touch points and improve underwriting efficiency (lower underwriting cycle time, cost per decision).
Common Application Processing job titles: Application Processor, New Business Representative
Underwriting
The medical Underwriting function is responsible for assessing health insurance applicants and making decisions on coverage. The applicant's health information (and other information submitted with their insurance application) is used to decide whether to offer or deny coverage and what the premium policy rate will be. Health insurance underwriters weigh the probable health risks of their applicants against the potential costs of providing coverage. They use data and guides developed by the Actuarial team to make pricing and coverage decisions based on risks associated with the potential member's health "profile" (age, location, medical history, daily habits, etc.).
Common Underwriting job titles: Underwriter, Medical Underwriter, Underwriting Analyst, Underwriting Support Specialist
Member Onboarding
The Member Onboarding function is responsible for ensuring that newly approved insurance policyholders (members) receive all of the required information to begin using the benefits of their policy. They send ID cards, educational materials, and information on in-network healthcare providers to new members. They also ensure that all of the required account information is in good order and stored in company systems for analysis and retrieval.
Common Member Onboarding job titles: Member Service Representative, Customer Service Representative, Customer Support Specialist
Claims Processing
The Claims Processing function is tasked with examining and processing insurance claims, paper and/or electronic. Processors determine whether to return, pend, deny or pay claims within the client's policy guidelines and determine steps necessary for adjudication. In addition, claims processing compares claim applications and/or provider statements with policy files and other records to evaluate completeness and validity of claim.
Common Claims Processing job titles: Medical Claims Processor, Medical Claims Auditor, Medical Claims Examiner
Actuarial
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.
Common Actuarial job titles: Actuarial, Actuarial Data Scientist, Actuarial Analyst
Sales & Business Development
The Health Insurance Sales and Business Development function is responsible for selling health insurance products to potential members. Health insurance can be sold through multiple channels - through the phone, over the internet, through branch offices (in-person) or through captive and/or independent health insurance agents or brokers. Sales staff work to educate sales leads on health plan benefits, premium structures and in-network providers. Health insurance products include individual plans, family plans, group plans (for employers) and government-sponsored options (medicare, medicaid) for different coverage types (health, dental, vision, pharmacy, etc.).
Common Sales & Business Development job titles: Insurance Agent, Insurance Broker, Sales Support 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, pharmacies, 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 (typically health insurance payers recieve discounted prices for provider services), manage relationships with providers and educate them on support options offered by the healthcare payer (i.e., the insurance company).
Common Network Development & Management job titles: Provider Relations Specialist, Provider Contracting Specialist
Provider Contracting
The Provider Contracting function is responsible for identifying, auditing and negotiating contract details with healthcare providers (physicians, specialists, pharmacists, dentists, hopspitals, clinics, etc.) that are eligible to join the health insurance company's network. Healthcare providers provide discounted rates to health insurance companies in exchange for a steady stream of patients that are directed to use their services (because they are "in-network" providers). Contract details include the rates (i.e., fee schedule) at which the provider will charge the insurance company for various types of services (based on claims codes), contract termination guidelines, and policies for any out-of-network care rendered by the provider.
Common Provider Contracting job titles: Provider Contracting Specialist, Provider Contract Analyst
Provider Services
The Provider Services function develops and delivers services to in-network healthcare providers (physicians, specialists, pharmacists, dentists, hopspitals, clinics, etc.), including electronic claims payments/transfers, claims support (submission codes, electronic submission, self-service), prior authorization submission and processing, educational resources and referral submissions.
Common Provider Services job titles: Provider Support Specialist, Provider Service Representative
Patient Education & Wellness Programs
The Patient Education and Wellness Programs function develops and implements educational programs and other tools aimed at fostering healthy habits within the insurance company's member population. They offer resources related to dieting, exercise, mental health and drug use - all aimed at helping policyholders understand ways to improve and maintain their health. Some health insurance companies are even starting to offer rewards programs that incentivize policyholders to maintain a healthy and active lifestyle. Patient Education groups may also develop and publish studies related to the efficacy of certain drugs and/or the effects of certain diseases/conditions.
Common Patient Education & Wellness Programs job titles: Nutritionist, Member Relations Analyst, Research Scientist, Content Specialist