Group Life Claims Examiner

Our client, a provider of life insurance and STD and LTD, is looking to bring on a Group Life Claims Examiner for a three to six month assignment. This role is 100% remote.

Job Function:

Under minimum supervision, this position is responsible for reviewing and processing of life claims for Group Insurance policies. Performs a variety of related duties including timely follow up, accurate assessment of supporting information, appropriate adjudication of these claims with optimum outcomes, and customer service.

Job Responsibilities:

* Adjudicate claims by Group policy provisions.

* Review, research, verify and diligently obtain information on all claims assigned to determine eligibility for benefits

* Assume responsibility for all assigned large accounts and sensitive groups to review and resolve customer problems and complaints concerning claims matters and personally handles the claim through resolution.

* Maintain required levels of confidentiality

* Maintain thorough knowledge of policies, statutes and regulations, medical conditions and departmental procedures to ensure proper dispositions of claims.

* Interpret and administer contract provisions including, but not limited to, eligibility, employee and dependent coverage amounts, late entrant and evidence of insurability, open vs annual enrollment, definition of Total Disability, reduction schedules, facility of payment and contestable investigations.

* Consistently adhere to the documented workflow guidelines and established procedures to meet or exceed quality, production, service objectives and performance guarantee standards.

* Promptly and thoroughly investigate and evaluate claims, validate coverage amounts according to contract, process payments or denials in accordance with department procedures and compliance with Unfair Claims Practice regulations.

* Document claim file actions and telephone conversations appropriately.

* Proactively communicate and respond to claim inquiries from insureds, beneficiaries, attorneys, policyholders, reinsurers, State Insurance Department and internal stakeholders; resolve issues through effective verbal and written communication by involving appropriate people within, or outside the department or company; effectively and professionally represent the company in all interactions.

* Provide professional and positive customer service through prompt, accurate and courteous experience via telephone interviews, follow up calls and correspondence in writing to members, groups, county representatives, etc., to obtain required information, determine extent of customer concern and resolves situation in accordance with standard operating procedures.

* Utilize Department resources, reports and system functionality to properly manage assigned work in a timely manner

* Proactively identify inconsistencies or lag in claim information and utilize effective approaches and resources to obtain clarification or verification.

* Maintain accurate documentation of activities in claim file in accordance with established guidelines.

* Examine and analyze life claim information and finalize benefit decisions and payments on claims up to $100,000 aggregate liability following prescribed procedures.

* Approve or deny claims within department authority limits and follow prescribed process of referring claims outside authority, rescission or settlement of disputed claims to Supervisor/Manager for review.

* Collaborate with team members and management in identifying and implementing improvement opportunities. Inform Supervisor of any trends noted within specific client companies.

* Coordinate, with the Actuary Department in submission of claims under the correct reinsurance treaties.

* Maintain records and reports, may analyze data.

Required Job Qualifications:

• Bachelor’s degree and 4 years of business experience or 2 years of life claims experience.
• MUST have Accidental, Critical Illness, and Hospital Indemnity claim adjudication experience.
• Experience in processing any of the following claim types a plus: Wellness benefit, GAP, Accidental Death and Dismemberment, and Accelerated Death Benefits.

Skills Required:

• PC proficiency to include Microsoft Word, Excel and Outlook.
• Excellent math aptitude, analytical and critical thinking skills.
• Good decision making skills – ability to analyze complex claim information.
• Excellent Customer Service skills.
• Clear and concise verbal and written communication skills.
• Problem solving and research skills.
• Experience handling multiple tasks and managing priorities.
• Detail oriented with ability to maintain high level of quality and accuracy while meeting productivity targets in a fast-paced environment
• Knowledge of state regulations, statutes and ERISA in reference to Life and waiver of premiums.

Preferred Job Qualifications:

* LOMA courses.

* Ability to fluently speak and write Spanish a plus.

* Preferred experience in the following core systems: ECM, STAR (Claim System), Genelco/GIAS, Siebel, UTS, UWPro, Casetrak, Benefits Manager, and ImagePlus.

If this sounds like you, please apply today!