QUALIFICATIONS/REQUIREMENTS:
- Bachelor of Arts or Sciences degree in business field, related field, or equivalent work experience
- At least 4 years of practical insurance claim experience
- The ability to use resources effectively, exercising good judgment, possessing decision-making ability, and applying knowledge and experience to related situations so that many types of requests can 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.
- Demonstrates knowledge of company administrative systems, and software. Familiarity with computer and Windows PC applications, which includes 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; determine if additional data is necessary; calculate the benefits payable and any interest due; insure that valid claims are reviewed and paid in a prompt and equitable manner or declines payment of benefits when loss is not covered under the terms and provisions of the policy. The maximum claim authority per file is $10,500.00.
- Provide superior customer service to claimants or their representatives through written correspondence, telephone, and face-to-face contact in a courteous, tactful, and appropriate manner. 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 as workload or absence dictates to ensure claims are handled in a timely manner
- Order investigations on suicide, homicide, and accidental death claims to determine Company’s liability. Investigate abandoned property cases and comply with regulations. 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 decline claims
- Approve and request claim expense checks for outside investigations and attorney’s fees
- Continually expand knowledge of human anatomy and 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.
- Perform other department duties as assigned by Manager
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