Claims Examiner

About the role

As a Claims Examiner specializing in Life, Accident, Critical Illness, Long-Term Care (LTC), and Hospital Indemnity lines of business, you will accurately assess and process claims related to these insurance products. Your role involves investigating claims, verifying policy coverage, determining liability, and ensuring compliance with regulatory requirements. Strong analytical skills, attention to detail, and empathy are essential as you interact with claimants, healthcare providers, and other stakeholders to facilitate timely and fair claim settlements.

Responsibilities

• Evaluate incoming claims to determine eligibility, coverage, and validity.
• Conduct thorough investigations, including reviewing medical records and other relevant documentation.
• Analyze policy provisions and contractual agreements to assess claim validity.
• Utilize claims management systems to document findings and process claims efficiently.
• Communicate effectively with policyholders, beneficiaries, and healthcare providers regarding claim status and requirements.
• Provide timely responses to inquiries and maintain professional and empathetic communication throughout the claims process.
• Address customer concerns and escalate complex issues to senior claims personnel or management as needed.
• Ensure compliance with company policies, procedures, and regulatory requirements.
• Maintain accurate records and documentation related to claims activities.
• Follow established guidelines for claims adjudication and payment authorization.
• Identify opportunities for process improvement and efficiency within the claims department.
• Participate in quality assurance initiatives to uphold service standards and improve claim handling practices.
• Collaborate with team members and management to implement best practices and enhance overall departmental performance.
• Generate reports and provide data analysis on claims trends, processing times, and outcomes.
• Contribute to the development of management reports and presentations regarding claims operations.
• Actively adopt and leverage emerging AI tools to improve workflows, solve problems, and drive efficiency.
• Use a range of AI-enabled tools (such as copilots, chat-based AI, and automation solutions) as part of everyday work.

Requirements

• Bachelor’s degree in business administration, insurance, healthcare management, or a related field (or equivalent work experience).
• Prior experience in claims processing, preferably in Accident, Critical Illness, LTC, and/or Hospital Indemnity insurance.
• Knowledge of insurance principles, policies, and practices related to accident, critical illness, LTC, and hospital indemnity lines of business.
• Strong analytical and problem-solving skills with the ability to interpret complex documents and policies.
• Excellent communication skills, both verbal and written, with a customer-focused approach.
• Proficiency in using claims management software and Microsoft Office Suite (Excel, Word, Outlook).

Preferred Skills

• ACS and/or ALHC Designation.
• Experience with medical terminology and healthcare billing practices.
• Understanding of regulatory requirements governing claims processing in the insurance industry.

Attributes

• Demonstrated strong punctuality and attendance practices.
• Detail-oriented with a commitment to accuracy and thoroughness.
• Ability to work effectively in a team environment and independently when necessary.
• Strong organizational skills with the ability to prioritize and manage multiple tasks.
• Adaptable to changing priorities and comfortable working in a fast-paced environment.
• Curiosity and willingness to actively adopt and leverage emerging AI tools.

Schedule

Regular business hours (9:00 AM – 6:00 PM Eastern). Occasional overtime or weekend work may be required during peak periods or to meet deadlines.

Work Environment

Remote work environment. Opportunities for professional development and career advancement within the claims department or broader insurance organization.