Medical Claims Consultant

Overview

Operating within the core values and operating principles of the organization, the Medical Claims Consultant is responsible for providing medical and business expertise and knowledge in support of claims decisions. This role’s primary responsibility is to serve as a resource to the claims team including contestable claims examiners, Accident and Health examiners, claims consultants and management with respect to denials, appeals, escalations or complex medical questions that arise in the processing of claims.

• Serve as a resource to the contestable claims team. This includes review of contestable claims as needed by claims personnel.
• Review of medical documentation including physician and hospital records, accident reports or other clinical materials
• Review and understanding of policy language – interpret policy exclusions and endorsements in relation to medical findings
• Review all contestable claim denials, including those that may have potential to result in litigation
• Identify inconsistencies or gaps in medical documentation and recommend additional information when needed.
• Serve as a resource to claims consultants and management with regards to denials, appeals or escalations that involve medical decisions
• Resource to the entire claims team with respect to complex medical decisions that arise in the day-to-day handling of claims. Assist in determining whether a claim is eligible under policy language and with respect to any supporting medical documentation.
• Provide training for claims examiners on medical topics relevant to claims decision making
• Support claim work related to denials or appeals that require medical decision making
• Participate in training and round tables, providing medical expertise in support of claims decision making.
• Collaborates closely with claims examiners, underwriters, legal counsel and potentially third parties to ensure accurate and fair claims decisions
• Maintain up-to-date knowledge of relevant medical standards, diagnostic/treatment guidelines, and regulatory/industry developments that impact claim adjudication

• Doctorate or Advanced healthcare degree (MD, DO, BA-PA (Physician Assistant Bachelor’s Degree in conjunction with PA certification), PA-C, NP, RN) with demonstrated claim-consulting or clinical review experience
• Clinical experience (min 5-10 years) with a strong familiarity of a broad range of medical conditions, treatments or outcomes

• Experience in the life insurance industry
• Excellent ability to interpret and synthesize complex medical records, and to translate findings into actionable claims decisions.

While performing the duties of this job, the employee is frequently required to stand, walk, sit, use hands to finger, handle, or feel, talk, hear and concentrate. Specific vision abilities required by this job include close vision, distance vision, depth perception, and ability to adjust focus.

This job requires the ability to perform duties contained in the job description for this position, including, but not limited to, the above requirements. Reasonable accommodation will be made for otherwise qualified applicants as needed to enable them to fulfill these requirements.

We are committed to ensuring equal employment opportunities for all job applicants and employees. Employment decisions are based upon job-related reasons regardless of an applicant's race, color, religion, sex, sexual orientation, gender identity, age, national origin, disability, marital status, genetic information, protected veteran status, or any other status protected by law.