Claim Examiner

Overview

Examines, investigates and evaluates information from policyholders, attorneys, physicians, hospital personnel, police departments, employers, State Medicaid personnel, funeral homes, Probate courts and other professionals needed to determine the disposition of life, annuity, health and disability claims within authority limits. Benefit and coverage decisions made are susceptible to litigation and/or significant monetary damages. In addition to claim handling, handles second-level support calls from the Client Relationship Center (CRC) and direct customer support to clients and financial representatives (i.e. outbound calls to settle express claims). Provides prompt and courteous customer service to external and internal customers and provides job-specific training for new hires in addition to training on specialized processes.

Responsibilities

What you will do:

• Independently reviews and evaluates claims submitted on the company's life, annuity, health and disability products.
• Determines the company's liability using knowledge of policy provisions, medical terminology, disability duration, state regulations and tax requirements.
• Assures claim processing and payment procedures for death, cancer, ordinary/industrial accident and health and total and permanent disability claims according to company procedures and meets the appropriate state regulations.
• Determines proper payees, calculates benefits and releases payments up tp $100,000 on life insurance claims, $300,000 on annuity claims and $10,000 on critical illness claims. Conducts and controls investigations on contestable, accident, foreign and homicide claims up to $10,000.
• Handles client support calls, providing prompt and courteous service to internal clients, external clients and financial representatives.
• Exercises independent judgment in defining the nature and scope of the investigation.
• Selects outside investigation firms when appropriate and manages the costs associated with each investigation.
• Works directly with our Law Department to draft legal releases, affidavits, authorizations and agreements to settle a claim.
• Maintains compliance with applicable federal and state laws (e.g., HIPAA) related to privacy, security, confidentiality, and protection of personal information, including, but not limited to, personal health information, financial information, and personally identifiable information.
• Maintains comprehensive knowledge of state regulations and tax requirements that pertain to fixed annuity and life insurance claim processing.
• Responsible for completing project work as assigned by management.
• Projects include but are not limited to completing various monthly, quarterly and yearly reports.
• Performs other duties as assigned.
• Complies with all policies and standards.

Qualifications

• High School Diploma High school diploma, some college work preferred. - Preferred
• Demonstrated knowledge of claims administration including payment options, contract provisions and tax ramifications. - Preferred
• Must provide examples from work experience of maintaining a high degree of accuracy and excellent organizational skills associated with high volumes of work and/or multiple duties. -
• Demonstrated experience working effectively within a team. -
• Demonstrated excellent verbal and written communication skills with the ability to successfully interpret and communicate business needs to internal or external customers in a clear, focused and concise manner. -
• Demonstrated experience acquiring and assimilating new knowledge and skills. -
• Demonstrated experience identifying and resolving problems where independent decision-making and initiative were demonstrated. -
• Must provide examples of working under multiple deadlines and minimal supervision. -
• Demonstrated experience and proven strong analytical skills in identifying and quantifying problems arising from customer, policy/procedural changes, etc., and providing effective recommendations to resolve. -
• Working knowledge of word processing, spreadsheet and Microsoft Office applications. -
• LOMA 280 and 290, and 50% completion of ALHC designation (ICA) preferred and/or commensurate experience as outlined in the selection criteria section. Upon Hire - Preferred

Work Setting/Position Demands:

• Works in an office setting and remains in a stationary position for long periods of time while working at a desk, on a computer or with other standard office equipment, or while in meetings.
• Requires the ability to verbally communicate and exchange accurate information to customers and associates on a regular basis.
• Requires visual acuity to read and interpret a variety of correspondence, procedures, reports and forms via paper and electronic documents, visual inspection involving small defects; small parts, and/or operation of machinery (including inspection); using measurement devices continuously. Visual acuity is required to determine accuracy, neatness, and thoroughness of work assigned.
• Requires the ability to prepare written correspondence, reports and forms using prescribed formats and conforming to rules of punctuation, grammar, diction, and style on a regular basis.
• Requires the ability to apply principles of logical thinking to define problems, collect data, establish facts, and draw valid conclusions
• Performs substantial movement of wrists, hands, and fingers for continuous computer work.
• Extended hours required during peak workloads or special projects/events.

Travel Requirements:

• None