Evaluates and analyzes documentation necessary for claim payments or denials according to the policy/certificate provisions and state regulations with limited authority limits.
Responsibilities Evaluates and analyzes documentation thoroughly to determine claim processing according to policy/certificate provisions and state regulations with limited authority limits.
Analyzes any additional information/documentation received to determine how to proceed with a review of a claim under supervision and determines methods of obtaining information from alternative sources.
Manages the review of a claim and the outside sources used in the review.
Thoroughly documents correspondence and conversations.
Corresponds verbally and in writing with claimants, medical providers, medical examiners, and law enforcement.
Works closely with manager claims examiner, legal counsel, medical director, claims assistants, and other departments.
Monitors claims for fraud and proceeds accordingly.
Infrequently testifies in depositions, hearings and trials; communicates the Company’s position regarding the claim.
Maintains compliance with regulations and respond to any insurance department complaints.
Qualifications Bachelors degree or equivalent work experience required.
Up to 2 years experience in claims.
Quickly learn product language and provisions.
Preferred Qualifications Strong organizational, problem solving and analytical skills.
Flexible and adaptable to change.
Multi task skills.
Working Conditions Normal office environment.