Claim Auditor

Job Summary

Review, analyze, investigate, and authorize payment of benefits within authority guidelines and in accordance with the established guidelines and terms of the policy/contract.

• Analyze and evaluate claim/benefit request forms and documents to determine eligibility based on policy/contract provisions. Based on evaluation of information received determine to pay, deny or require additional information to make payment determination.
• Enter claims data into claim administrative system and document relevant information.
• Compose correspondence to banks, agents, lawyers, hospitals, doctors, claimants/protected, or beneficiaries on payment determination or to obtain additional or missing information to make determination. Utilize standardized letters in routine cases; modify as needed.
• Correspond and answer phone calls from insureds, beneficiaries, banks, doctor's offices, agents, or attorneys regarding submitted claims/benefit requests, status, and policy/contract provisions. Document discussions on claim system.
• Perform claim reviews of medical information and accuracy of the application to determine if eligibility requirements were met at time of issue. Also, make the determination whether any of the policy/contract exclusions apply. Refer cases of undisclosed health history to legal for further review. If it is determined misrepresentation of health history occurred that would impact coverage eligibility, then handle the request appropriately.
• Review life claims to assure the correct beneficiary has made claim for the proceeds. Review the beneficiary designated and determine if the beneficiary is eligible for payment.
• At time of payment of a life claim, review state requirements to determine if required to perform a data match of beneficiaries against a Child Support Division database in attempt to intercept payments to a parent who may be in default of child support obligations.
• Identify and document potential cases of fraud and refer file to Legal department for determination of fraudulent activity.
• Provide support to home office sales force and accounts with claim/benefit requests questions and status concerns and to ensure consistent communication.
• Follow-up on pending claims/benefit requests and information requested.
• Stay abreast of state requirements and industry changes. Also requires knowledge of all protection options offered and available through our Credit Union accounts.
• Assist with special projects and duties as assigned including backup and coverage for other areas.
• Interact with other department members to resolve problems and inquiries and to allow for efficient data and information flow.
• Perform other related duties as assigned.

• Associates Degree in Business, or other complimentary discipline, or equivalent experience.
• Five years of claim auditing experience, with progressively responsible levels of duties and accountabilities. months previous work experience.
• Customer service experience requiring resolutions of issues.
• Solid computer skills, working with various software packages to retrieve and document information.
• Exceptional verbal and written communication skills. Ability to interact effectively and professionally with both internal coworkers and external contacts. Strong attention to detail and organizational abilities.

• Attainment of professional insurance designations or other insurance designations preferred.
• Medical terminology course and industry courses such as Health Insurance Association of American (HIAA), ICA, and LOMA helpful.
• Previous experience within credit insurance or life claims preferred.
• Customer service experience in environments requiring resolution of sensitive matters.