Job description

Job Title: Associate Life & Disability Examiner

Location: Houston and Richardson - Texas

Duration: 8+ Months Contract to hire

Job Responsibilities:

· Assume responsibility for all assigned large accounts and sensitive groups to review and resolve customer problems and complaints concerning claims matters and personally handles the claim through resolution.

· Proactively communicate and respond to claim inquiries from insureds, beneficiaries, policyholders and internal stakeholders; resolve issues through effective verbal and written communication by involving appropriate people within, or outside the department or company; effectively and professionally represent the company in all interactions.

· Relieve and complete work assignments for other Claim Representatives during absences, etc. to stay within the Department's established turnaround schedule.

· Investigate, research, verify and diligently obtains medical information on all claim types to determine eligibility and interpret information relating to the severity of the stated disability or incident.

· Adjudicate claims in accordance with established policies and procedures.

· Interview, make calls and/or corresponds with customers to determine extent of customer concern and resolves situation in accordance with standard operating procedures.

· Proactively identify inconsistencies or lag in claim information and utilize effective approaches and resources to obtain clarification or verification.

· Obtain complete and accurate information from groups, agencies, physicians, claimants, etc., to verify and ensure claim eligibility and/or continued disability.

· Maintain accurate documentation of activities in claim file in accordance with company practices and procedures.

· Maintain thorough knowledge of all policies, statutes and regulations, medical conditions and departmental procedures to ensure proper dispositions of claims.

· Recommend changes to management to avoid recurring customer inquiries/problems.

· Adhere to quality, production, service, and departmental guidelines to process claims.

· Provide professional, prompt, and accurate customer service via telephone and in writing to members, groups, doctors, etc., in handling various claim types.

· Approve or deny claims within policy limits; recommend approval, denial, rescission, or settlement of disputed claims.

· Communicate with outside attorneys, group representatives, claimants, reinsurers, and the State Board of Insurance to exchange information and respond verbally or in writing to inquiries.

· Assist in the preparation of grievance summaries and information for lawsuits.

· Coordinate, with various reinsurance companies, the gathering of information and submission of claims under the reinsurance treaties.

· Research cases of concern to the State Insurance Department; compiles data and composes response letter for approval by Manager.

Required Job Qualifications:

· Bachelor’s degree or 4 years of business experience.

· 1 year of claims experience.

· Problem solving and research skills.

· PC proficiency includes Word, Excel, PowerPoint, Outlook, and Lotus Notes.

· Customer Service experience.

· Organizational skills.

· Experience handling multiple tasks and making priorities.

· Clear and concise verbal and written communication skills.

Preferred Job Qualifications:

· LOMA courses.

· Aptitude for math and critical thinking skills.

· Knowledge of state regulations, statutes, and ERISA.

· Detailed oriented.

· Knowledge in any of the following: Correspondence, Medical Records Review, Misrepresentation Investigation, Pre-Existing Investigation, Evidence of Insurability Review, Benefit Entitlement Review, Financial Accuracy, ERISA Guidelines, MAR Requirements, State Regulations, Contract Language, Company Financial Liability.

· Knowledge in any of the following core systems: ECM, STAR (Claim System), Genelco/GIAS, Siebel, UTS, Casetrak, Docsql, Benefits Manager, and ImagePlus.

· Knowledge in one (1) of the following claim types: Life or Waiver of Premium claims.

· Knowledge in any of the following two (2) claim types: Critical Illness/Specified Disease, Accidental Insurance, GAP, Permanent and Total Disability (PTD benefits, Accidental Death and Dismemberment, Permanent and Total Disability (PTD), Accelerated Death Benefits.

Job Types: Full-time, Contract

Pay: $23.00 - $24.00 per hour

Ability to commute/relocate:

• Houston, TX: Reliably commute or planning to relocate before starting work (Required)

Work Location: In person

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