Underwriting interview prep.

Underwriters across commercial group + individual + Medicare Advantage + Medicaid + self-insured + stop-loss + specialty lines.

What interviewers look for

  • Can the candidate price + assess risk for the lines of business this firm operates - group + individual + MA + Medicaid + stop-loss?
  • Do they understand the regulatory framework - ACA MLR, state rate filings, Medicare Advantage bid process, Medicaid actuarial soundness?
  • Are they fluent in risk adjustment - HCC + RAF + RA reconciliation - the lever that makes or breaks payor economics?
  • Can they think through provider network economics - UCR, fee schedules, network discounts, narrow vs broad?
  • Do they understand medical management + utilisation - the cost side of the MLR equation?
  • Are they commercially aware - producer + broker dynamics, employer benefit design, member engagement?
  • Can they navigate value-based + alternative payment models - capitation, shared savings, bundled payments?

Behavioural questions to expect

  1. Walk me through your background + underwriting experience.

    What it tests: Story arc - quantitative training, underwriting / actuarial / commercial exposure, regulatory awareness.

  2. Tell me about a book of business you've underwritten or analysed.

    What it tests: Underwriting + analytical thinking - pricing, profitability, retention, regulatory + commercial framing.

  3. Why payor underwriting vs other actuarial / underwriting paths?

    What it tests: Authentic alignment - healthcare economics, multi-stakeholder, regulatory + commercial intersection.

  4. Why this line of business / segment?

    What it tests: Specificity. Generic answers fail.

  5. Why this firm?

    What it tests: Real homework - lines + markets + culture - not name-drop.

  6. What's your read on our lines of business + market position?

    What it tests: Industry literacy - line mix, geographic footprint, competitive position.

  7. Tell me what you understand about our financial + MLR + Stars performance.

    What it tests: Financial fluency - MLR, MA Stars, risk adjustment performance, line profitability.

  8. Walk me through a pricing or underwriting decision for a specific line of business.

    What it tests: Pricing rigor - manual rate + experience credibility + risk adjustment + regulatory + competitive.

Technical concepts to master

ACA commercial + group + individual underwriting

Modified community rating
ACA limits rating factors to age (3:1 max), tobacco (1.5:1 max), family composition, and geographic area.
Guaranteed issue + renewal
ACA requires issuers offering coverage to issue to any applicant + renew (with limited exceptions).
Experience rating (large group)
Large groups (>50 / >101 employees) can be experience-rated - claims history credible adjustment.
Self-insured + stop-loss
Self-insured groups bear claims directly; stop-loss insurer covers excess (specific or aggregate).

Medicare Advantage bid + Stars

MA bid process
Annual June 1 bid submission to CMS based on benchmark + Star bonus + risk-adjusted projections.
MA Stars rating
CMS 1-5 star rating on ~40 measures (HEDIS clinical, HOS, CAHPS, Part D + admin).
MA risk adjustment (RAF)
CMS HCC model adjusts capitation per member based on diagnosed conditions; RAF = Risk Adjustment Factor.
RADV + audit risk
CMS Risk Adjustment Data Validation audit reviews diagnoses for clinical support.

Risk adjustment + HCC + RAF

HCC (Hierarchical Condition Categories)
CMS-developed groupings of ICD-10 codes into ~80-90 categories that predict cost.
RAF (Risk Adjustment Factor)
Member-level score combining demographics + HCC coefficients - predicted cost vs average.
HCC capture + chart review
Process of ensuring all clinically valid diagnoses are captured each year via provider coding + chart review.
RA reconciliation
Annual reconciliation of risk scores with actual diagnoses + CMS payment adjustment.

Provider network economics + value-based contracts

UCR + fee schedule
Usual + Customary + Reasonable benchmark for non-network rates; in-network contracts use specific fee schedule.
Network adequacy + tiering
Regulatory requirement that members have reasonable access to in-network providers; tiered networks differentiate cost-share.
Capitation
Per-member-per-month payment to provider group regardless of services rendered - transfers risk + incentive.
Shared savings + bundled payments
Shared savings = provider receives % of savings vs benchmark. Bundled = single payment for episode (knee replacement, MI).

Practical drills

  • A 250-employee group is up for renewal. Last year MLR was 92% on $4.2M premium. They're shopping. Walk through your pricing analysis + renewal recommendation.
  • Your MA plan's RAF score dropped 3% YoY in mid-year submission. Walk through your diagnostic + response.
  • A major hospital system is asking for a 12% rate increase. They handle 35% of your members' inpatient admits. Walk through your analytical + negotiation approach.

Smart-question anchors

  • Lines of business + market - commercial / MA / Medicaid mix, geographic focus
  • Financial performance - MLR, MA Stars, RA reconciliation, line profitability
  • Underwriting org - functional structure, market vs national, actuary vs underwriter roles
  • Provider network strategy - broad / narrow / tiered, value-based contracting depth
  • Risk adjustment posture - HCC capture, RA reconciliation, audit history

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