Claims Examiner

Location: Candidate can work out of office locations in Lombard, IL, Richardson, TX, Southfield, MI, or Tulsa, OK (Hybrid role / 2 days a week in office)

Duration: 6-12+ Month Contract Position

Our client is looking to add a Claims Examiner that will be responsible for examining and processing all claim types including short term or long-term disability, life, waiver of premium, critical illness, accident insurance and other claim type for various policies.

Job Responsibilities:

• Assume responsibility for all assigned large accounts and sensitive groups to review and resolve customer problems and complaints concerning claims matters and personally handles the claim through resolution.
• Proactively communicate and respond to claim inquiries from insureds, beneficiaries, policyholders and internal stakeholders; resolve issues through effective verbal and written communication by involving appropriate people within, or outside the department or company; effectively and professionally represent the company in all interactions.
• Relieve and complete work assignments for other Claim Representatives during absences, etc. to stay within the Department's established turnaround schedule.
• Investigate, research, verify and diligently obtains medical information on all claim types to determine eligibility and interpret information relating to the severity of the stated disability or incident.
• Adjudicate claims in accordance with established policies and procedures.
• Interview, make calls and/or corresponds with customers to determine extent of customer concern and resolves situation in accordance with standard operating procedures.
• Proactively identify inconsistencies or lag in claim information and utilize effective approaches and resources to obtain clarification or verification.
• Obtain complete and accurate information from groups, agencies, physicians, claimants, etc., to verify and ensure claim eligibility and/or continued disability.
• Maintain accurate documentation of activities in claim file in accordance with company practices and procedures.
• Adhere to quality, production, service and departmental guidelines to process claims.
• Provide professional, prompt and accurate customer service via telephone and in writing to members, groups, doctors, etc., in handling various claim types.
• Approve or deny claims within policy limits; recommend approval, denial, rescission or settlement of disputed claims.
• Communicate with outside attorneys, group representatives, claimants, reinsurers, and the State Board of Insurance to exchange information and respond verbally or in writing to inquiries.
• Assist in the preparation of grievance summaries and information for lawsuits.
• Coordinate, with various reinsurance companies, the gathering of information and submission of claims under the reinsurance treaties.
• Research cases of concern to the State Insurance Department; compiles data and composes response letter for approval by Manager.

Required Job Qualifications:

• Bachelor’s degree or 2-3 years of business experience.
• 1-2 years of claims experience.
• Problem solving and research skills.
• PC proficiency to include Word, Excel, PowerPoint, Outlook and Lotus Notes.
• Customer Service experience.
• Organizational skills.
• Experience handling multiple tasks and making priorities.
• Clear and concise verbal and written communication skills.
• Proficient in the following: Correspondence, Medical Records Review, Misrepresentation Investigation, Pre-Existing Investigation, Evidence of Insurability Review, Benefit Entitlement Review, Financial Accuracy, ERISA Guidelines, MAR

Requirements, State Regulations, Contract Language, Company Financial Liability.

• Experience in the following core systems: ECM, STAR (Claim System), Genelco/GIAS, Siebel, UTS, Casetrak, Docsql, Benefits Manager, and ImagePlus.
• Experience processing one (1) of the following claim types: Life or Waiver of Premium claims.
• Experience in processing any of the following two (2) claim types: Critical Illness/Specified Disease, Accidental Insurance, GAP, Permanent and Total Disability (PTD benefits, Accidental Death and Dismemberment, Permanent and Total Disability (PTD), Accelerated Death Benefits.