Claims Examiner I - Supplemental Health

*other duties as assigned*

The Supplemental Health Claims Examiner I evaluates and processes lines coverage handled in the Supplemental Health Claims Department in accordance with applicable law and company guidelines. Claims may include Wellness, Accident, Critical Illness, and Hospital Indemnity benefits. The goal of the role 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.

Analysis and Adjudication

• 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.

Research

• 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.

Case Management

• 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.

Customer Service

• 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.

REQUIRED KNOWLEDGE, SKILLS, ABILITIES, COMPETENCIES, AND/OR RELATED EXPERIENCE

*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 …