Our client, a provider of life insurance and short-term and long-term disability insurance, is looking to bring on a Group Life Claims Examiner. Under minimum supervision, the examiner will be responsible for reviewing and processing life claims for group insurance policies. This role performs a variety of related duties, including timely follow up, accurate assessment of supporting information, appropriate adjudication of claims with optimum outcomes, and customer service. This opportunity is anticipated to be 3 months in duration and is hybrid out of the client's office in Illinois.
Responsibilities
Adjudicate claims by group policy provisions.
Review, research, verify and diligently obtain information on all claims assigned to determine eligibility for benefits.
Assume responsibility for all assigned large accounts and sensitive groups, including reviewing and resolving customer problems and complaints concerning claims matters and personally handling claims through resolution.
Maintain required levels of confidentiality.
Consistently adhere to the documented workflow guidelines and established procedures to meet or exceed quality, production, service objectives and performance guarantee standards.
Maintain thorough knowledge of policies, statutes and regulations, medical conditions, and departmental procedures to ensure proper dispositions of claims.
Interpret and administer contract provisions.
In accordance with department procedures and in compliance with unfair claims practice regulations, promptly and thoroughly investigate and evaluate claims, validate coverage amounts according to contracts, and process payments or denials.
Document claim file actions and telephone conversations appropriately.
Proactively communicate and respond to claim inquiries from insureds, beneficiaries, attorneys, policyholders, reinsurers, the state insurance department and internal stakeholders.
Resolve issues through effective verbal and written communication, involving appropriate people within or outside the department or company, as needed.
Provide professional and positive customer service through prompt, accurate and courteous telephone interviews, follow-up calls and written correspondence to members, groups and county representatives to obtain required information, determine the extent of the customer's concern and resolve the situation in accordance with standard operating procedures.
Utilize department resources, reports and system functionalities to properly manage assigned work.
Proactively identify inconsistencies in claims information and utilize effective approaches and resources to obtain clarification or verification.
Maintain accurate documentation of activities in claims files in accordance with established guidelines.
Examine and analyze life claims information and finalize benefit decisions and payments on claims up to $100,000 aggregate liability following prescribed procedures.
Approve or deny claims within department authority limits and follow the prescribed process of referring claims outside authority to supervisor for review.
Collaborate with team members and management to identify and implement improvement opportunities.
Inform supervisor of any trends noted within specific client companies.
Coordinate with the actuarial department to submit claims under the correct reinsurance treaties.
Requirements
Bachelor’s degree
4 years of business experience or 2 years of life claims experience
Experience with accidental, critical illness and hospital indemnity claims adjudication
Experience processing wellness benefits, GAP, accidental death and dismemberment, or accelerated death benefits claims (preferred)
Proficiency using Microsoft Word, Excel and Outlook
Excellent mathematical, analytical and critical thinking skills
Good decision-making and problem-solving skills
Ability to analyze complex claims information
Excellent customer service skills
Clear and concise verbal and written communication skills
Experience handling multiple tasks and managing priorities
Ability to maintain high level of quality and accuracy while meeting productivity targets in a fast-paced environment
Knowledge of state regulations, statutes and ERISA in reference to life and waiver of premiums
Fluent in Spanish (preferred)
Preferred experience with ECM, STAR, Genelco/GIAS, Siebel, UTS, UWPro, Casetrak, Benefits Manager, or ImagePlus systems (preferred)