Claims Examiner I or II

This position could be hybrid or possibly fully remote depending on level of experience.

About the role

In this role, you will be responsible for securing and analyzing claim information to determine the approval or denial of claims related to Life, Annuity, and Cancer products and benefits. The role involves making informed claims decisions in accordance with the terms of the contract, performing detailed analysis and documentation of claim data to direct effective outcomes, and meeting risk management and regulatory requirements in accordance with WoodmenLife’s policies and practices. The claim examiner communicates with claimants, beneficiaries, health providers, or others to gather information and clarify details of the claims. Claims examiners are responsible for the adjudication and payment of all types of claims for life, annuity, and health products.

Responsibilities

Claims Examiner I – Non-Exempt

• Handles all administrative duties for Life and Health Claims, including but not limited to:
  • Comparing and analyzing death notifications against the Client System of Record and taking appropriate action.
  • Entering and coding all new deaths or health claims into administrative systems.
  • Mailing claim paperwork and checks.
• Examines death or health claims on life and annuity insurance certificates and cancer products. Reviews applications, claim forms, certified death certificates, and any additional documentation to assure that a valid death has occurred and the correct beneficiary has made a claim for the proceeds.
• Reviews the beneficiary designation and determines if the beneficiary is eligible for payment.
• Upon demonstration of required skills and competencies:
  • Life – independent approval limits up to $75,000.
  • Cancer – independent approval limits up to $25,000.
• Makes calls to funeral homes verifying needed information to process claims with face amounts that qualify as “quick” claims.
• Determines if adjustments are needed to the benefit amounts WoodmenLife is liable for based on the date of death, date of birth, and applicable interest rates.
• At the time of payment, reviews state requirements to determine if WoodmenLife is required to perform a data match of its beneficiaries against a Child Support Division database in an attempt to intercept payments to a parent who may be in default of their child support obligations.
• Continually reviews and analyzes workflow to provide efficient service and meet service level goals. Makes recommendations for changes that enhance the process and improve customer service.

Claims Examiner II – Non-Exempt

Proficient in all Level I duties and 75% of Level II duties.

• Upon demonstration of required skills and competencies:
  • Life & Annuity – independent approval limits up to $300,000.
  • Cancer – independent approval limits up to $60,000.
• Processes annuity and settlement options death claims, including Variable Annuities.
• Identifies the type of annuity to be paid. Determines if the beneficiary is eligible to receive the elected distribution option under WoodmenLife policies and procedures and IRS regulations.
• After confirmation of the elected distribution method, completes claim processing, calculates the net gain, determines federal/state withholding, creates tax forms for each beneficiary, and coordinates with other departments to ensure ownership changes are updated accordingly.
• Communicates with families, sales associates, funeral homes, attorneys, CPAs, law enforcement agencies, healthcare providers, or facilities to answer a wide variety of questions.
• Performs initial review and adjudication of Waiver, Accelerated Benefit Rider, and Continued Proof Health Claims.
• Researches and processes any inquiries on claim disbursements as needed.

Requirements

• High school diploma or equivalent education/work experience.
• Demonstrates knowledge of WoodmenLife products and knowledge of Core Operations systems, policies, and procedures.
• Demonstrates in-depth problem-solving capabilities, including the ability to detect discrepancies, trends, and efficiencies needed.
• Ability to understand and then clearly communicate information and answers to Home Office associates and external customers.
• Ability to provide and receive constructive feedback.
• Ability to maintain confidentiality, sensitivity, and professionalism.
• Ability to work well with others in a team environment.
• Ability to work with a high level of concentration and attention to detail.

Claims Examiner I

• Knowledge of GLBA along with other state and federal regulations.

Claims Examiner II

• Proficient in all Level I skills.
• The ability to work with little or no direction from Senior Examiner or Supervisor.
• Prefer 2+ years of previous experience in claims processing for life and health.

Benefits

We offer a comprehensive benefits package including:

• Health, dental, and vision insurance.
• 401(k).
• Life insurance.
• And more.

As part of WoodmenLife’s employment process, candidates will be required to complete a criminal background check, credit check (when required for the position), fingerprint check (when required for the position), drug screen, and reference checks. Any offer of employment will be contingent upon successfully passing the above.