Health Claims Examiner

Location - Lombard, IL (3 days a week onsite)

Our client is looking to add a Supplemental Health Claims Examiner that will be responsible for analyzing, processing, and recommending approval or denial of Hospital Indemnity, Critical Illness/Specified Disease, Accident Insurance, Life product claims, and weekly income claims on various policies with a variety of related duties.

Job Responsibilities:

• Adjudicate Accident Insurance, Critical Illness/Specified Disease, Hospital Indemnity Life product claims and weekly income claims in accordance with established policies and procedures.
• Consistently adhere to the documented workflow guidelines and established procedures.
• Calculate multiple benefits due based a combination of information on claim forms, medical information, plan certificates/contract and regulatory guidelines and administer provisions accurately, including, but not limited to, misrepresentation or pre-existing Investigation, Evidence of Insurability Review, Benefit Entitlement Review, Financial Accuracy, ERISA Guidelines, MAR Requirements, State Regulations, Company Financial Liability as applicable.
• Proactively and efficiently obtain complete and accurate information from groups, agencies, physicians, beneficiaries, claimants, etc., to verify and ensure claim eligibility and resolve investigation issues.
• Maintain or exceed Department production, quality, and service level standards consistently.
• Provide professional, prompt, and accurate customer service via telephone and in writing to members, groups, doctors, etc., in handling various claim types.
• Assume responsibility for all assigned claims to review and resolve customer issues/problems and complaints promptly.
• Investigate, research, and verify information on all claim types to confirm eligibility and ensure sufficient/adequate information is obtained related to benefits being claimed.
• Maintains required levels of confidentiality.
• Provide effective verbal and written communication by involving appropriate parties within, or outside the department or company to professionally represent the company in all interactions.
• Maintain accurate documentation of activities and telephone conversations in claim file in accordance with company practices and procedures.
• Maintain thorough knowledge of all policies, statutes and regulations, medical conditions, and departmental procedures to ensure proper dispositions of claims.
• Recommend changes to management to avoid recurring customer inquiries/problems.
• Fully investigate all relevant claim issues, provide approvals, payments, or denials promptly and in full compliance with departmental procedures and Unfair Claims Practice regulations.

Required

Job Qualifications:

• Associate’s or Bachelor’s degree or 0-2 years of equivalent business/related work experience.
• Good decision-making, problem solving and research skills with ability to analyze complex information.
• PC proficiency to include MS Word, Excel, SharePoint, and Outlook.
• Detail oriented with ability to maintain high level of quality and accuracy in a fast-paced environment.
• Clear and concise verbal and written communication skills.
• Knowledge of medical terminology

Preferred

Job Qualifications:

• HIAA, LOMA or ICA courses a plus.
• Aptitude for math and critical thinking skills.
• Ability to fluently speak and write Spanish a plus.

The anticipated hourly rate range for this position is ($22-25/hr). Actual hourly rate will be based on a variety of factors including relevant experience, knowledge, skills and other factors permitted by law. A range of medical, dental, retirement and/or other benefits are available after a waiting period.