Ancillary Claims Examiner

Job Summary:

The Claims Examiner I is responsible for adjudicating individual and group voluntary benefits claims, including Critical Illness, Accident, Hospital Indemnity, Short Term Disability, Short Term Care, and Life products. This role ensures the accurate entry of claims data while conducting thorough reviews and analyses to determine eligibility.
As an entry-level position, the Claims Examiner I works closely with more senior examiners to ensure the accurate and timely processing of claims. This role supports the company's mission by maintaining high standards of accuracy and efficiency in claims adjudication.

Key Responsibilities:

• Deliver exceptional service to claimants, internal teams, and external customers, aligning with company values.
• Process and adjudicate routine claims for Critical Illness, Accident, Hospital Indemnity, Short Term Disability, Short Term Care, and Life products under direct supervision.
• Investigate, resolve, and make decisions on less complex claims, ensuring full compliance with company policies and industry regulations.
• Ensure claims are processed in compliance with company policies and industry regulations.
• Meet or exceed minimum production averages and accuracy targets for payment, procedure, and financial goals.
• Participate in the development and implementation of policies and procedures to improve claim handling processes.
• Assist in enhancing claims processes to boost operational efficiency while maintaining compliance.
• Consistently meet production and accuracy targets, including payment, procedure, and financial goals.
• Collaborate with team members and other departments to ensure seamless claims handling and customer service.
• Day-to-Day Activities:
• Review and enter claims data accurately.
• Conduct thorough reviews and analyses to determine eligibility.
• Communicate with claimants and other stakeholders to gather necessary information and provide updates.
• Research and resolve discrepancies in claims data.
• Participate in team meetings and training sessions to stay updated on policies and procedures.
• Contribute to various claims-related projects and process improvement initiatives.

Qualifications:

• High school diploma or equivalent required; Bachelor's degree preferred.
• Minimum of 1 year of claims experience preferred, with exposure to group and/or individual products.
• Basic understanding of claims processing and settlement practices.
• Strong communication and interpersonal skills.
• Ability to manage multiple priorities and meet deadlines.
• Basic knowledge of regulatory standards and compliance requirements .

Skills:

• Analytical Skills: Ability to review claim details, medical records, and policy provisions to make informed decisions. Claims examiners must analyze information to determine coverage and benefits accurately.
• Attention to Detail: Precision in reviewing documentation, identifying discrepancies, and ensuring all required information is present before making a decision. This skill is crucial for accurate claim adjudication.
• Communication Skills: Strong written and verbal communication abilities to clearly explain claim decisions to stakeholders. Claims examiners must also effectively communicate with internal teams.
• Time Management: Efficient handling of multiple claims and tasks, ensuring timely adjudication within set deadlines. Time management is vital for managing high workloads and meeting service-level agreements.
• Problem-Solving: Capacity to address complex claims scenarios, interpret policy language, and find solutions to claims issues. Claims examiners need to resolve questions or disputes related to coverage.
• Knowledge of Policy Provisions: Deep understanding of policy terms, conditions, and exclusions for accident indemnity, hospital indemnity, short-term care, critical illness, and disability coverage. This is necessary for accurate application of benefits.
• Regulatory Compliance Awareness: Knowledge of relevant insurance laws and regulations to ensure all claims are handled in compliance with legal and regulatory requirements.

Work Environment / Physical Requirements:

The work environment is a standard office setting with typical office equipment. This role involves professional collaboration with colleagues and clients. Responsibilities may involve extended periods of sitting, occasional walking between departments or meeting rooms, and periodic standing, reaching, stooping, and lifting office items weighing up to 25 pounds.