Claim Examiner

Overview:

Summary of Responsibilities:

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. 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. Verifies all requirements received before closing claim files on completed claims, codes statistical data related to cause of death and aids in the production of monthly and quarterly reports. Researches and completes projects of various magnitudes.

Position Responsibilities:

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  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 meet the appropriate state regulations.

• Determines proper payees, calculates benefits and releases payments within authorized limits to assure that the Company is fully discharged from liabilities associated with claims.

• Conducts and controls investigations on contestable and accident claims on policies with face amounts under $10,000 and claims for disability premium waiver. 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.

• Identifies claims that meet qualifications for payment via Life Accounts and completes processing necessary to set up the accounts.

• Conveys claim decisions to the beneficiary through reasoned, clear, concise and well-constructed written correspondence while following proper rules of punctuation, grammar, dictation and style.

• Reviews their own and other associates’ paid claims for accuracy and completeness. Verifies that all needed information was received, and codes statistical data regarding cause of death as required.

• Provides guidance and direction to the claim approver staff on claim issues including payee problems, accounting discrepancies and transaction errors.

• Provides concurrence for other Senior Approvers on contestable claim payments. Concurs with Claim Analyst on contestable claim rejections.

• Inputs claims into systems, maintains pending files, matches output to the appropriate file and distributes new mail.

• Responsible for completing project work as assigned by management. Projects include but are not limited to completing various monthly, quarterly and yearly reports.

• Provides prompt and courteous handling of escalated and second-level calls routed from the Customer Service representatives including coverage questions, complaints related to benefit decisions and explanations of claim requirements providing clear, concise and accurate information to the caller.

• Performs other duties as assigned by management.

Selection Criteria:

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  Demonstrated knowledge of claims administration including payment options, contract provisions and tax ramifications.

• 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 knowledge and experience with various claims administration systems and/or processes. Ability to continuously make repetitive motions of the wrists, hands and/or fingers.

• Demonstrated experience working effectively within a team. Must provide examples from work experience of going beyond the call of duty to assist team members.

• 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. This would include strong telephone communication and etiquette skills.

• Proven experience adapting and demonstrating flexibility associated with changes to policies/procedures.

• Demonstrated experience acquiring and assimilating new knowledge and skills. Must be able to cite examples of work experience wherein new skills were applied to complete assigned tasks successfully.

• Experience must include 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.

Work Setting:

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  This position works in an office setting and remains continuously 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.
  

Educational Requirements:

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  High school diploma.

• Some college work preferred.

Computer skills and knowledge of hardware & software required:

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  Working knowledge of word processing, spreadsheet and Microsoft Office applications.

Certifications & licenses (i.e., Series 6 & 63, CPA, etc.):

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  None required.

Position Demands:

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  Extended hours required during peak workloads or special projects.