Supplemental Health Examiner

About the role

The role of Supplemental Health Examiner supports the accurate and timely adjudication of supplemental health and life insurance claims within a high-volume claims environment.

Responsibilities

• Evaluate and review claim forms to determine coverage amounts, eligibility, policy requirements and payment procedures.
• Cooky with other parties to ensure seamless integration of claim process.
• Contact Claimants to notify by telephone or letter to verify questionable information submitted on claims.
• Create, review and edit member and benefit information including Self-Administered Billing, Self-Administered Billing-Web, Third Party Administrators, spouse and dependent coverages.
• Update party records and roles, benefit cases and benefit entitlements as it relates to claims.
• Complete Intake scripts and E-Forms.
• Maintain thorough knowledge of all policies, state statutes, regulations, ERISA, and departmental procedures to ensure proper dispositions of claims.
• Adhere to group special handling or preference in claim follow up activities.
• Provide professional, prompt and accurate customer service to both internal and external customers.
• Adhere to quality, production, service and departmental guidelines to complete claims with diligent follow-ups.
• Proactively identifies inconsistencies or lag in claim information and utilizes effective approaches and resources to obtain clarification or verification.
• Communicate and interact effectively and professionally with co-workers, management, customers, etc.
• Maintain accurate Claim documentation of activities in claim file, systems and all communication, in a clear professional and approved format that is in accordance with company practices and procedures.
• Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
• Keep the superior informed of any pertinent developments or questionable claims which could have an adverse effect on the company.
• Maintain complete confidentiality of company business.
• Maintain communication with management regarding development within areas of assigned responsibilities.
• Recommend changes to management to avoid recurring customer inquiries/problems.
• Review, analyze, and meticulously code the following claim types: Accident Insurance, Hospital Indemnity & Critical Illness.

Qualifications

• A High School Diploma OR GED and 1 year of claims experience OR Bachelor degree and 1 year of insurance experience.
• Customer Service experience.
• Organizational skills.
• Ability to handle multiples tasks at once.
• Knowledge of state regulations, statutes, and ERISA.
• Clear and concise verbal and written communication skills.
• PC proficiency in Word, Excel, PowerPoint, Lotus Notes.
• Knowledge of ECM, STAR (Claim System), Genelco/GIAS, Salesforce, Benefits Manager, and Index Assist Tool.
• (Preferred) Aptitude for math and critical thinking skills.
• (Preferred) Knowledge of state regulations, statutes, and ERISA.
• (Preferred) Detailed oriented.