Interprets medical and contractual information in the assessment of benefits payable under disability contracts. Provides excellent customer service both in written and verbal communications.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
Determines employee eligibility, benefit amount/duration and certifies that the claim proofs submitted meet the definition of total disability under the provisions of the contract.
Handles telephone inquires relative to claims status and makes outbound calls for acquiring information necessary to validate and adjudicate claims.
Performs investigations involving Pre-existing and Contestable conditions. This includes requesting medical records and evaluating their content upon receipt and making written recommendations to the carrier on action to be taken on these cases.
Follows directions for claims requiring special handling as provided by carrier, company consultant and/or policy terms.
Evaluates processes and suggest innovations to increase the overall effectiveness of the process.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.
Education and Experience:
Associates degree and 1+ years claims examining experience, preferably with disability or workers compensation; or an equivalent combination of education and experience
Strong communication and customer service skills
Attention to detail and ability to multi-task
Certifications and Licenses:
NYS Independent Accident & Health Insurance Adjuster
Pearl - 21 months ago