Case Specialist, Supplemental Health

Sun Life•Portland, ME

9d•Remote

About The Position

The Case Specialist, Supplement Health Claims manages initial liability claims submitted for Critical Illness, Cancer, Hospital Indemnity and Accidental claims. They work independently and autonomously managing each claim by conducting a thorough review and investigation, determining what additional resources are appropriate to collaborate with and deciding the initial and future liability of each claim.

Requirements

Minimum 1-year previous work experience in financial, medical, and/or customer service field
High School Diploma required
Attains and maintains appropriate TPA licenses in accordance with the Claims Licensing Policy
Solid analytical, critical thinking, problem solving and decision-making skills
Ability to interpret and communicate contract language
Excellent verbal communication skills, with the ability to be both pleasant and professional
Strong written communication skills
Solid mathematical skills
Ability to work well independently and in a team environment
Strong interpersonal and customer service skills
Ability to initiate and prioritize regular work duties and projects
Detail oriented, organized, the ability to multi-task, and strong time management skills
Strong computer skills, proficient in a PC environment and MS Word, Excel, and email systems
Ability to work professionally and effectively with co-workers, clients, claimants, vendors, and others with whom FullscopeRMS does business

Nice To Haves

college degree preferred
Experience in Supplemental Health, Case Administrator role preferred

Responsibilities

Reviews and investigates Critical Illness, Cancer, Hospital Indemnity and Accidental claims by using the telephone and written contact with the applicable parties, e.g. claimant, employer, treating physicians and client carrier partner, to gather pertinent data to analyze each claim.
Investigates the claim level eligibility by accessing the client carriers’ systems.
Resolves eligibility issues by collaborating with employers and partners at the client company.
Adjudicates claims and benefits accurately and fairly, in accordance with the contract, appropriate policies and procedures, and state and federal regulations, while meeting productivity and quality standards.
Utilizes clinical staff, adhering to referral policies.
Conducts in-depth pre-existing condition reviews and contestable investigations.
Thoroughly reviews all medical records and additional information submitted to accurately calculate and communicate all benefits payable in a timely manner.
Develops and maintains online claims data.
Interprets, understands, and communicates the policy that governs each claim.
Mentors and trains new hires as requested.