Evaluate and analyze documentation for claim payments or denials according to the policy/certificate provisions and state regulations, with limited authority limits.

Responsibilities

  • Under direct supervision, analyze information/documentation received to determine how to proceed with a review of a claim and determine methods of obtaining additional information from alternative sources.
  • Review claims and outside sources used in the review.
  • Document correspondence and conversations.
  • Correspond verbally and in writing with claimants, medical providers, medical examiners, and law enforcement.
  • Work closely with department manager, legal counsel, medical director, claims assistants, and other departments to gather information for contested claims.
  • Monitor claims for fraud and proceed according to each situation, such as engaging the Fraud team or additional research.
  • Maintain compliance with regulations.


Qualifications

  • Associate’s degree in a business field or equivalent experience
  • Excellent communication and customer service skills
  • Organizational, problem-solving and analytical skills
  • Ability to cross train and learn other products
  • Ability to multi-task and adapt to change


Preferred Qualifications

  • Claims experience


Working Conditions

  • Office/Hybrid/Remote (Call Center) Environment

Compensation

The salary for this position generally ranges between $38,000-42,000 annually. Please note that the salary range is a good faith estimate for this position and actual starting pay is determined by several factors including qualifications, experience, geography, work location designation (in-office, hybrid, remote) and operational needs. Salary may vary above and below the stated amounts, as permitted by applicable law.

Additionally, this position is typically eligible for an Annual Bonus of 6% based on the Company Bonus Plan/Individual Performance and is at the Company’s discretion. 


This job description is not a contract of employment nor for any specific job responsibilities. The Company may change, add to, remove, or revoke the terms of this job description at its discretion. Managers may assign other duties and responsibilities as needed. In the event an employee or applicant requests or requires an accommodation to perform job functions, the applicable HR Business Partner should be contacted to evaluate the accommodation request.