• Evaluates, processes and/or audits claims that require moderate to complex judgement and investigation such as Accident, Critical Illness, HRA, FSA Claim Adjustments, New Short Term Disability or Medlink claims in accordance with Company policy terms, insurance laws, regulatory requirements and adjusting guidelines.
• Provides appropriate verbal and/or written communication to internal and external Customers in a positive and knowledgeable manner to ensure a high standard of Customer service. Meets standards established in department performance metrics for appropriate handling of Customer phone calls.
• Acts as a direct contact and communicates with internal and external Customers and medical providers in a positive, knowledgeable and professional manner, providing them with direction and assistance in all facets of insurance coverage and needs.
• Process, audit and/or adjusts claims in accordance with Company policy, insurance laws, regulatory requirements, adjusting guidelines and department performance metrics. Communicate with appropriate parties to verify and document claim requests. Refer claims to internal and external consultants when necessary. For HRA, handles billing and collection of deposits for reimbursement.
• Respond to Customer inquiries by providing accurate information to ensure a high level of quality service and satisfaction. Uses past experience, contract/law knowledge, good judgment and common sense in claim processing and Customer communications. Follow through on Customer concerns to ensure timely and appropriate resolution. Assist less experienced team members as needed to resolve Customer concerns. Meet standards established in department performance metrics for appropriate handling of Customer phone calls.
• Correspond with outside parties (insureds, medical providers, consultants, employers) to communicate claim position; follow-up on pending claims and other outstanding issues to ensure such issues are resolved in a timely manner. Follow through on Customer complaint resolution and record the complaint and resolution.
• Provide training and guidance, utilizing personal experience and knowledge, to fellow team members in an effort to enhance and grow their ability to satisfy the Customer with improved knowledge, skills, good judgment and common sense.
• Cross trains on and processes claims outside of primary responsibility as requested by department management.
• Perform other duties as requested by department management.
Job Requirements:
• Associates Degree preferred
• Prompt and reliable
• Good understanding of medical terminology and physiology
• Possesses PC Windows-based software knowledge, including intermediate proficiency in Microsoft Office applications, with the ability to train on new applications and work in a paperless environment
• Knowledge of insurance claims processes and regulations, preferred
• Knowledge of case management tools and ability to apply
• Good analytical skills
• Good communication skills, both verbal and written
• Good interpersonal skills (team orientation)
• Ability to multi-task in a fast paced environment
• Ability to be flexible in work schedule, including a willingness to work overtime as needed
• Good judgment skills
• Organizational skills
• Professional attitude
• Dedicated to providing world-class Customer service
• Ability to work well within a team environment Bilingual candidate preferred