Job Description

Primarily responsible for providing professional customer service to insureds, members, and accounts. To enforce contractual requirements impartially and expeditiously. Adjudicate, pend, investigate and/or deny claims by verifying submitted information, coverage issued and documentation provided. Identify claims of a potentially fraudulent nature and refer to management for review. Monitor and process claims to meet the demands of a production environment and to adhere to established service standards. May process various types of claims, mainly reimbursement of benefits directly to the member.

• Enters claim information and adjudicates claim by reviewing information and taking appropriate action to pay, request additional information or deny benefits based on coverage, provisions, and exclusions as outlined in the master policy certificate, including endorsement for eligibility and or liability.
• Investigates claims of a potentially fraudulent nature and reviews findings with management.
• Communicates with members, employers, accounts, and vendors to retrieve information to validate claims.
• Analyzes information and makes payments or adjustments as needed.
• Maintains appropriate claims related statistics and documentation to be provided to the legal department in the event of lawsuits, insurance department inquiries, SSAE16 audits, or other internal or external audits.
• Maintains an understanding of related state laws, anti-fraud compliance requirements, claims processes, product standards, production standards, company guidelines and service standards.
• Maintains tracking system by updating the computer system with claims numbers and verifies coverages.
• Identifies potential workflow improvements and impediments.

The above cited duties and responsibilities describe the general nature and level of work performed by people assigned to the job. They are not intended to be an exhaustive list of all the duties and responsibilities that an incumbent may be expected or asked to perform.

Qualifications

• High School Diploma of equivlaent
• 2 years of experience on PC
• 2 years’ experience in claims and/or other related claims processes
• Knowledge of and experience with AS/400 system experience preferred
• Customer Service training is imperative since we communicate verbally on the phone and in written correspondence
• Fraud Awareness training and Claims Experience required.

Additional Information

Full benefit package including medical, dental, life, vision, company paid short/long term disability, 401(k), tuition assistance and more.

All your information will be kept confidential according to EEOC guidelines.