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Claims Examiner



Category

Enterprise Operations --> Claims

Job Location

17900 N. Laurel Park Dr, Livonia, MI

Tracking Code

1946-418

Position Type

Full-Time/Regular

Consistent with our service philosophy of speed, accuracy, and style, this individual analyzes, evaluates, and determines final decision for life, accidental injury & death, simple annuity and rider claims within scope of authority and experience level in accordance with established departmental and statutory guidelines. May consult with senior claims staff of management regarding claim situations that require assistance. Has authority to approve or deny claims within specified authority. Provides secondary signature for claims adjudicated by other team members within scope of authority. Has authority to resolve complaints and is actively involved in procedure development. Communicates with members, beneficiaries, and legal representatives to appropriately adjudicate a claim. Provides guidance and support regarding questions on claim files to less tenured team members. Senior Claims Examiner or Claims Consultant review cases outside of prescribed limits and authority. May also assist with projects and performs other duties as assigned.

 

Position Responsibilities

 

  • Review and assess newly reported life, accidental injury & death, simple annuity claims. May also review and assess specified Rider Claims, including Disability Waiver of Premium and Accelerated Death Benefit claims. May handle claims occurring outside of the US.
  • Analyzes requirements to determine accurate claim decision based upon specific contract for life, accidental injury & death, simple annuity and rider claims within prescribed limits and authority. Refers cases outside of prescribed limits and authority to Senior Claims Examiner or Claims Consultant.
  • Calculates benefits, including statutory interest, for life, accidental injury & death, simple annuity and rider claims.
  • Responds to customer inquiries regarding claim matters and written correspondence via telephone, written letter, and e-mail.
  • May conduct interviews with claimants, beneficiaries, or next of kin on any type of claim to gather information to adjudicate claim.
  • Acts as a mentor and provides secondary signature on claims referred to them by Claim Examiner I team members that are within scope of authority.
  • Prepares beneficiary correspondence to communicate adverse decisions when appropriate consistent with department guidelines and statutory requirements.
  • Process multiple types of Claims.
  • Supports accomplishment of team goals by performing other duties as assigned.
  • Represent Claims department in the legal process if required.
  • Read and interpret complex insurance policies/provisions as they relate to the claim presented.
  • Reads and interprets Reinsurance Treaties related to claim processing. Refers files to reinsurance in accordance with treaty requirements.

 


Required Skills

  • Achieves Results/Has Bias for Action - Achieves stretch results. Strong bias for action with sense of urgency and high energy.  Practices collaborative working environment to achieve more.
  • Customer Focus - Has ability to look from customer’s view. Viewed as business partner by external and internal customers.  Anticipates customer needs to ensure no barriers to doing business.
  • Uses Effective Communication Skills - Candid, clear and concise in communication. Effectively matches style, tone and method to audience.  Connects with intended audience.  Manages communication and feedback within the organization.
  • Displays Team Orientation - Works collaboratively to achieve organization’s success.
  • Technical/Professional Skills - Strives to stay ahead of technical/professional expertise, is proactive and inspires others to stay current in areas of technical expertise.
  • Problem Solving and Analysis – Able to gather appropriate data and diagnose the cause of a problem before taking action; separate causes from symptoms; apply lessons learned from others who encountered similar problems or challenges; anticipate problems and develop contingency plans to deal with them; develop and evaluate alternative courses of action.
  • Attention to Detail – Able to review data/documents for accuracy and consistency; take action to prevent mistakes; follow procedures closely; keep records accurate and up to date; test services/applications rigorously when needed.
  • Planning/Time Management – Accurately scopes out length and difficulty of tasks and projects; can orchestrate multiple activities at once to accomplish a goal; uses resources effectively and efficiently; arranges information and files in a useful manner; uses his/her time effectively and efficiently.

Required Experience

  • Associate Degree, medical certification, or equivalent related work experience required.
  • LOMA281 and LOMA2911) required within 12 months of starting position.
  • ALHC Designation required within 24 months of starting position.
  • Minimum 3 years’ experience in Life/Health Insurance or Claims processing experience or related field required.
  • Life insurance underwriting experience including knowledge and understanding of medical conditions, impairments and the financial and legal aspects of risk selection and other factors pertaining to acceptability and assessment of life insurance applications, preferred.
  • Demonstrates strong knowledge and understanding of Life, Accident, Annuity, and Heath Products Completion of AAA Life Insurance Company Product training within 6 months of accepting position.
  • Demonstrates knowledge of HIPAA, Privacy, ACLI Guidelines, Unfair Claims Settlement Act/Laws, Life Insurance and Medical Terminology.
  • Proficient using internet based applications and Microsoft office products, specifically Word and Excel.
  • Able to perform basic mathematical calculations to include addition, subtraction, multiplication, division, and percentage.
  • Able to work hours as required by business needs (may include flex scheduling, irregular hours, weekends, and holidays).

PM21

This position is located at 17900 N. Laurel Park Dr, Livonia, MI. View the Google Map in full screen.



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