Claims Examiner Supplemental Health

In this role, you will serve as a Supplemental Health Claims Examiner I, evaluating and processing lines coverage handled in the Supplemental Health Claims Department according to applicable law and company guidelines. Claims may include Wellness, Accident, Critical Illness, and Hospital Indemnity benefits. The goal is to consistently pay the accurate amount for each claim in accordance with the contract. This role also provides customer service that is respectful, prompt, concise, and accurate in an environment with competing demands.

* other duties as assigned*

Reviews and processes Wellness, Accident, Critical Illness, or Hospital Indemnity claim documents and proofs to verify eligibility based on contractual provisions and premium status within company guidelines and applicable law. Authorizes claim payments up to $5,000. Determines proper payee, verifies the accuracy of benefit amount calculations, and any applicable interest calculations and processes benefit payments up to $5,000. Processes system tasks and pending claims in accordance with department guidelines.

Provides payment or denials promptly and in full compliance with department procedures and regulations.

Develops an understanding and working knowledge of products, policies and contracts. Develops an understanding of the applicable contract/policy definitions of disability and relevant provisions, clauses, exclusions, as well as statutory requirements. Reviews medical and applicable information to verify eligibility. Determines proper payee, verifies the accuracy of benefit amount calculations, premium amount calculations under contributory plans, and any applicable interest calculations. Fully investigates all relevant claim issues.

Provides clear, concise and accurate information to claimants as well as within the claims administrative system. Creates necessary correspondence for benefit denials, partial denials, or eligibility denials. Manages assigned case load as outlined in Key Measures. Requests any necessary additional information from the policyholder and medical providers, or vendors when needed. Utilizes most efficient means to obtain claim information.

Provides customer service that is respectful, prompt, concise, and accurate in an environment with competing demands. Establishes, communicates, and manages claimant and policyholder expectations. Documents claim file actions and telephone conversations appropriately.

• * or equivalent experience gained from any combination of formal education, on-the-job training, and/or work and life experience
  * Required Knowledge, Skills, Abilities and/or Related Experience
• High School Diploma or equivalent required.
• Relevant Associates or Bachelor’s Degree highly preferred.
• Minimum of one (1) year related claims experience preferred.
• Work experience in decision-making and information analysis.
• Requires excellent communication skills.
• Demonstrated prioritization and organization skills.
• Experience working in confidential/protected identification environments.
• Good math and calculation skills.
• Proficient in Microsoft Office products.
• Prior experience using an automated claim system desirable.
• Ability to Travel:
  None

When used in the description below, the following terms are defined as: “Occasional”: done only from time to time, but necessary when it is performed. “Frequent”: regularly performed; generally an act that is required on a daily basis. “Continuous”: typically performed for the majority of an employee’s shift. Sitting for prolonged periods of time, frequently…