Location: Candidate can work out of office locations in Lombard, IL, Richardson, TX, Southfield, MI, or Tulsa, OK (Hybrid role / 2 days a week in office)
Duration: 6-12+ Month Contract Position
Our client is looking to add a Claims Examiner that will be responsible for examining and processing all claim types including short term or long-term disability, life, waiver of premium, critical illness, accident insurance and other claim type for various policies.
Job Responsibilities:
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.
Proactively communicate and respond to claim inquiries from insureds, beneficiaries, policyholders 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.
Relieve and complete work assignments for other Claim Representatives during absences, etc. to stay within the Department's established turnaround schedule.
Investigate, research, verify and diligently obtains medical information on all claim types to determine eligibility and interpret information relating to the severity of the stated disability or incident.
Adjudicate claims in accordance with established policies and procedures.
Interview, make calls and/or corresponds with customers to determine extent of customer concern and resolves situation in accordance with standard operating procedures.
Proactively identify inconsistencies or lag in claim information and utilize effective approaches and resources to obtain clarification or verification.
Obtain complete and accurate information from groups, agencies, physicians, claimants, etc., to verify and ensure claim eligibility and/or continued disability.
Maintain accurate documentation of activities in claim file in accordance with company practices and procedures.
Adhere to quality, production, service and departmental guidelines to process claims.
Provide professional, prompt and accurate customer service via telephone and in writing to members, groups, doctors, etc., in handling various claim types.
Approve or deny claims within policy limits; recommend approval, denial, rescission or settlement of disputed claims.
Communicate with outside attorneys, group representatives, claimants, reinsurers, and the State Board of Insurance to exchange information and respond verbally or in writing to inquiries.
Assist in the preparation of grievance summaries and information for lawsuits.
Coordinate, with various reinsurance companies, the gathering of information and submission of claims under the reinsurance treaties.
Research cases of concern to the State Insurance Department; compiles data and composes response letter for approval by Manager.
Required Job Qualifications:
Bachelor's degree or 2-3 years of business experience.
1-2 years of claims experience.
Problem solving and research skills.
PC proficiency to include Word, Excel, PowerPoint, Outlook and Lotus Notes.
Customer Service experience.
Organizational skills.
Experience handling multiple tasks and making priorities.
Clear and concise verbal and written communication skills.
Proficient in the following: Correspondence, Medical Records Review, Misrepresentation Investigation, Pre-Existing Investigation, Evidence of Insurability Review, Benefit Entitlement Review, Financial Accuracy, ERISA Guidelines, MAR
Requirements, State Regulations, Contract Language, Company Financial Liability.
Experience in the following core systems: ECM, STAR (Claim System), Genelco/GIAS, Siebel, UTS, Casetrak, Docsql, Benefits Manager, and ImagePlus.
Experience processing one (1) of the following claim types: Life or Waiver of Premium claims.
Experience in processing any of the following two (2) claim types: Critical Illness/Specified Disease, Accidental Insurance, GAP, Permanent and Total Disability (PTD benefits, Accidental Death and Dismemberment, Permanent and Total Disability (PTD), Accelerated Death Benefits.