Job Description :
Essential Job Functions
Conducts correspondence related to client requests for information.
Evaluates available information to validate claims. Verifies policyholder information, policy effective dates, premium status and verification of claim eligibility.
Identifies need for additional information; contacts appropriate source to obtain needed information. Verifies beneficiary or claimant information if claim is warranted.
Identifies payment amount and obtains required management approvals for payment. Processes payment.
Investigates highly complex claims and determines level of resolution if appropriate; advises claimant of status; negotiates settlement and resolution of claim.
Receives demand letters; researches and investigates claims, responds within individual parameters and escalates as appropriate.
Schedules work and monitors work performance, including production and quality standards, of lower level claims examiners, as needed.
Provides leadership and work guidance to less experienced personnel to ensure accuracy and timeliness of processing. Recommends personnel actions to management and may participate in performance evaluations or counseling employees.
Assists in claims financial reporting and reconciliation for client companies.
High school diploma or G.E.D.
Fellowship of Life Health Claims (FLHC) Certification preferred
Six or more years of insurance / claims processing experience
Experience working with insurance and / or medical terminology
Experience working with appropriate claims processing procedures and documentation
Strong analytical and problem solving skills
Strong interpersonal skills to interact with team members
Strong communication skills to communicate with clients
Strong negotiation skills to interact with claimant
Good human relations skills to provide leadership and work guidance to less experienced personnel
Ability to keep sensitive and confidential material private
Ability to work in a team environment