Essential Job Functions:
1. Determines eligibility of the most complex claims, including hose that fall within the pre-existing or contestable period of the contract.
2. Assists other representatives with interpretations of policy language and/or provides guidance and recommendations to appropriately handle their claims.
3. Investigates claims by determining the type and guiding the degree of involvement required of outside resources such as investigate agencies, independent medical reviewers, rehabilitation resources, workers compensation carriers, social security specialists or other government or financial agencies.
4. Adjudicates the most complex, difficult claims in accordance with established policies and procedures.
5. Maintains resisted claim activity log throughout the year for use in annual statement reporting.
6. Trains all new staff members on all benefit types; updates training manuals and provides suggestions for improvement; reviews and update regulatory/legal manuals for all 50 states and assists in communicating changes to the department or ensure proper claims processing.
7. Makes independent decisions' concerning denials, approvals and discontinuance of benefits. Coordinates recision and preexisting condition denials with the Supervisor.
8. Provides professional, prompt and accurate customer service via telephone and in writing to members, groups, doctors etc. in handling disability and EIB claims.
9. Communicates frequently with attorneys, group representatives, claimants, State agencies, reinsures and other insurance companies to exchange claim information.
10. Keeps the superior informed of any pertinent developments or questionable claims which could have an adverse effect on the company.
11. Compiles and reports all W2 tax information for existing groups to ensure accurate record keeping.
Position Requirements:
The selected candidate will meet the following criteria:
· Requires some college courses in business, industry-related education-LOMA or ICA course completion.
· Requires three years' disability or life claim experience.
· Demonstrated decision-making and critical thinking skills as related to claims adjudication.
· Ability to work independently and determine liability.
· Strong math skills and effective communication skills (both oral and written), with emphasis on high level of professionalism and customer service abilities.
· Ability to independently organize and maintain multiple priorities in a timely and accurate fashion.
· Knowledge of Word and Excel.
