Job Details

Job Summary:

This position is responsible for analyzing and processing insurance claims to determine the extent of the insurance carriers liability in a manner that supports the mission, values, and standards of the Company. Primary responsibilities include efficient adjudication of insurance claims, both phone and written communication with insureds, travel suppliers, medical facilities, and others, as well as maintaining all state Department of Insurance regulations for claims files. Weekends may be required. This position reports to the Claims Supervisor.

Principal Duties and Responsibilities:

Claims Processing and Coordination

1. Process all claims assigned in a timely, efficient, and accurate manner ensuring that all appropriate policies, procedures, and standard best practices are being followed.
2. Review information on claim forms, Physician Statement, and other documentation to ascertain completeness and validity of claim.
3. Correspond with insureds, physicians, agents, and other appropriate parties in order to obtain proper documentation and to finalize claim.
4. Maintain proper reserves on each claim file.
5. Ensure that proper file documentation is collected and maintained, including all records of correspondence and telephone conversations.
6. Investigate claims and direct the activities of outside adjusters and investigators.
7. Issue denial of benefits letters when appropriate.
8. Process attorney represented claims files.
9. Review and respond to Department of Insurance complaint letters.
10. Respond to written and phone inquiries regarding claims status.
11. Issue payments in a timely and accurate manner.
12. Ensure that current Federal and State insurance claims regulations, laws, and best practices are being employed consistently for all jurisdictions.

Customer Service

1. Answer questions and respond to inquiries from internal and external customers regarding coverage issues and general policy information.

Teamwork and Department Support

1. Assist in the mentoring and training of other employees as directed.
2. Perform other duties or special projects as assigned by management team.

Required / Desired Knowledge, Experiences and Skills:

1. Exceptional communication, problem-solving, and organizational skills.
2. Strong reading, writing, comprehension, and proofreading skills.
3. Knowledge of standard concepts, practices, regulations, and laws within insurance field preferred.
4. Bilingual English/Spanish language fluency verbal, reading, and writing skills, is a plus.

Education/Certifications:

1. High School Diploma or equivalent required; Bachelors degree (B.A.) from an accredited institution a plus.
2. Previous claims and customer service experience is highly preferred.

Physical Working Environment:

While performing the duties of this job, the employee is required to stand; walk; sit for long periods of time; use of hands to grasp, handle, or feel; reach with hands and arms; finger dexterity; talk; hear. The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl. The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception, and ability to adjust focus.

The above statements are intended to describe the general nature of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of employees so classified.