- Company Name
- IT Associates
- Job Title
- Health Claims Examiner
- Job Description
-
Job title: Health Claims Examiner
Role Summary:
Evaluate, process, and decide on hospital indemnity, critical illness, accident insurance, life product, and weekly income claims. Ensure compliance with policy, regulatory, and financial guidelines while maintaining high-quality customer service and documentation.
Expectations:
* Complete claims within established service levels.
* Accuracy in benefit calculations and adherence to regulatory standards (ERISA, MAR, State regulations).
* Maintain confidentiality and professional communication.
Key Responsibilities:
* Adjudicate claims for Accident, Critical Illness, Hospital Indemnity, Life, and Weekly Income.
* Calculate benefits, assess misrepresentation/pre‑existing conditions, review evidence of insurability, and ensure financial accuracy.
* Obtain complete data from groups, agencies, physicians, and claimants to verify eligibility.
* Resolve investigation issues, complaints, and customer inquiries promptly.
* Document all actions and communications in claim files.
* Maintain knowledge of policies, statutes, regulations, and medical terminology.
* Recommend process improvements to reduce recurring issues.
Required Skills:
* Decision‑making, problem‑solving, research analysis.
* Proficient in MS Word, Excel, Outlook, SharePoint.
* Strong customer service and communication (verbal/written).
* Detail‑oriented, quality‑focused, fast‑paced.
* Basic mathematical and critical thinking.
* Knowledge of medical terminology.
Required Education & Certifications:
* Associate’s or Bachelor’s degree, or 2–3 years equivalent business/related experience.
* Preferred: HIAA, LOMA, or ICA certification.
* Preferred: Knowledge of ERISA, state regulations, and claim systems (ECM, STAR, Genelco/GIAS, Salesforce, UTS, Benefits Manager).
* Preferred: Experience with Critical Illness/Specified Disease, Accident Insurance, Hospital Indemnity, or Short‑Term Disability.
* Preferred: Spanish fluency.