QUALIFICATIONS/REQUIREMENTS:
- Bachelor of Arts or Sciences degree in a business-related field or equivalent work experience.
- At least 4 years of practical insurance claim experience.
- Ability to use resources effectively, exercise good judgment, make decisions, and apply knowledge and experience to related situations to allow many types of requests to be handled independently.
- Ability to professionally interact with business people of all levels and succinctly communicate information to internal and external customers.
- General understanding of corporate multiline products, procedures, and practices.
- Demonstrated knowledge of company administrative systems and software. Familiarity with PC and Windows applications, including the ability to learn new and complex computer system applications.
- Regular and reliable attendance and punctuality is an essential function of this position
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DUTIES/RESPONSIBILITIES:
- Analyze claims and determine their validity based on policy provisions, riders, waivers, operating procedures, and state regulations. Calculate benefits payable and interest due. Ensure claims are paid in a prompt and equitable manner or decline payment for losses that are not covered.
- Provide superior customer service to claimants or their representatives. Prepare tax forms, state notice forms, and state consent forms when applicable.
- Maintain working knowledge of adjudication and reporting responsibilities within department and provide assistance to other examiners to ensure claims are handled in a timely manner.
- Order investigations on suicide, homicide, and accidental death claims. Investigate abandoned property cases. Administer reinsurance reporting and communication and assure proper reconciliation.
- Determine from medical records received, approval or denial of contestable claims; request medical information from doctors and hospitals as needed. Upon receipt, review and determine whether benefits are applicable and pay or deny claims.
- Approve and request claim expense checks for outside investigations and attorney’s fees.
- Continually expand knowledge of human anatomy, physiology, disease processes, and medical practices and procedures, and consult with Underwriting or Medical Director as needed.
- Continually expand knowledge of legal decisions, opinions, proper practices, and procedures, and consult with Legal department as needed. Alert to spot red flags for potential fraud instances.
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