Job Description

REMOTE – CLAIMS SPECIALIST

Location; Remote, US

JOB DESCRIPTION

• Analyze and evaluate death claims and accelerated death benefit claims including contestable or otherwise complex cases to determine coverage and / or contestability.
• Determine proper course of action or level of resolution if appropriate; communicate claim status or necessary requirements with claimant and all appropriate parties involved with the claim.
• Read and interpret insurance policies / provisions as they relate to the claim presented.
• Direct investigations by working closely with contracted investigative services to obtain medical records, financial history.
• Analyze investigation findings for material misrepresentations or evidence of fraud.
• Present findings to Risk underwriter and Claim committee.
• Apply established claim processes and procedures when adjudicating claims.
• Makes decisions within guidelines.
• Respond to customer inquiries regarding claim matters and written correspondence via telephone, written correspondence, and email in accordance with regulations.
• Prepares beneficiary correspondence to communicate adverse decisions when appropriate.
• Collaborate with Client Services and other areas in LID to resolve complex situations.
• Consults with management and Legal on claims investigations, denial, and rescissions as well as interpretation of contracts and regulations to direct and make decisions on claims.
• Represent Claims department in the legal process and depositions if required.

QUALIFICATIONS

• Minimum of 4 years college or equivalent education / experience including a minimum of 5 years life claims processing experience.
• Demonstrated ability to analyze, solve complex problems, and collaborate to find customer resolutions.
• Demonstrated ability to clearly communicate (verbal and written).
• Demonstrated time management and organizational skills.
• Ability to manage multiple priorities, utilizing strong analytical / decision making skills.
• Administrative insurance system experience strongly preferred.
• Completion of ALHC industry designation preferred.

Company Description

Platinum Resource Group is a professional level consulting firm, providing resources to Fortune 1000 client companies in the areas of technology, human resources, accounting, finance, business systems and supply chain, on a contract and interim basis. PRG has operations in Orange County, San Diego, Los Angeles and San Francisco. As a W-2 employer we offer our consultants direct deposit bi-weekly payroll, health, dental, vision benefits, paid holidays, and referral bonuses.