The Claims Examiner will be responsible for providing professional customer service to insureds, members, and accounts. This individual will enforce contractual requirements impartially and expeditiously. Additionally, they will adjudicate, pend, investigate and/or deny claims by verifying submitted information, coverage issued and documentation provided.
Minimum Qualifications:
- High School diploma or equivalent required.
- At least 2 years of experience in PC required.
- At least 2 years experience in claims and/other related claims processes required.
- Knowledge of AS400 system experience preferred.
- Property License, 220, or 620, is preferred.
Primary Job Functions:
- Enters claim information and adjudicates claim by reviewing information and taking appropriate action to pay, request additional information or deny benefits based on coverage, provisions, and exclusions as outlined in the master policy certificate, including endorsement for eligibility and or liability.
- Investigates claims of a potentially fraudulent nature and reviews findings with management.
- Communicates with members, employers, accounts, and vendors to retrieve information to validate claims.
- Analyzes information and makes payments or adjustments as needed.
- Maintains appropriate claims related statistics and documentation to be provided to the legal department in the event of lawsuits, insurance department inquiries, SSAE16 audits, or other internal or external audits.
- Maintains an understanding of related state laws, anti-fraud compliance requirements, claims processes, product standards, production standards, company guidelines and service standards.
- Maintains tracking system by updating the computer system with claims numbers and verifies coverages.
- Identifies potential workflow improvements and impediments.
The above cited duties and responsibilities describe the general nature and level of work performed by people assigned to the job. They are not intended to be an exhaustive list of all the duties and responsibilities that an incumbent may be expected or asked to perform.
Additional Information:
Full benefit package including medical, dental, life, vision, company paid short/long term disability, 401(k), tuition assistance and more.#LI-Onsite
