Claim Examiner

Western & Southern Financial Group•Cincinnati, OH

About The Position

Examines, investigates and evaluates information from policyholders, attorneys, physicians, hospital personnel, police departments, employers, State Medicaid personnel, funeral homes, Probate courts and other professionals needed to determine the disposition of life, annuity, health and disability claims within authority limits. Benefit and coverage decisions made are susceptible to litigation and/or significant monetary damages. In addition to claim handling, handles second-level support calls from the Client Relationship Center (CRC) and direct customer support to clients and financial representatives (i.e. outbound calls to settle express claims). Provides prompt and courteous customer service to external and internal customers and provides job-specific training for new hires in addition to training on specialized processes.

Requirements

Must provide examples from work experience of maintaining a high degree of accuracy and excellent organizational skills associated with high volumes of work and/or multiple duties.
Demonstrated experience working effectively within a team.
Demonstrated excellent verbal and written communication skills with the ability to successfully interpret and communicate business needs to internal or external customers in a clear, focused and concise manner.
Demonstrated experience acquiring and assimilating new knowledge and skills.
Demonstrated experience identifying and resolving problems where independent decision-making and initiative were demonstrated.
Must provide examples of working under multiple deadlines and minimal supervision.
Demonstrated experience and proven strong analytical skills in identifying and quantifying problems arising from customer, policy/procedural changes, etc., and providing effective recommendations to resolve.
Working knowledge of word processing, spreadsheet and Microsoft Office applications.

Nice To Haves

High School Diploma High school diploma, some college work preferred.
Demonstrated knowledge of claims administration including payment options, contract provisions and tax ramifications.
LOMA 280 and 290, and 50% completion of ALHC designation (ICA) preferred and/or commensurate experience as outlined in the selection criteria section. Upon Hire

Responsibilities

Independently reviews and evaluates claims submitted on the company's life, annuity, health and disability products.
Determines the company's liability using knowledge of policy provisions, medical terminology, disability duration, state regulations and tax requirements.
Assures claim processing and payment procedures for death, cancer, ordinary/industrial accident and health and total and permanent disability claims according to company procedures and meets the appropriate state regulations.
Determines proper payees, calculates benefits and releases payments up tp $100,000 on life insurance claims, $300,000 on annuity claims and $10,000 on critical illness claims. Conducts and controls investigations on contestable, accident, foreign and homicide claims up to $10,000.
Handles client support calls, providing prompt and courteous service to internal clients, external clients and financial representatives.
Exercises independent judgment in defining the nature and scope of the investigation.
Selects outside investigation firms when appropriate and manages the costs associated with each investigation.
Works directly with our Law Department to draft legal releases, affidavits, authorizations and agreements to settle a claim.
Maintains compliance with applicable federal and state laws (e.g., HIPAA) related to privacy, security, confidentiality, and protection of personal information, including, but not limited to, personal health information, financial information, and personally identifiable information.
Maintains comprehensive knowledge of state regulations and tax requirements that pertain to fixed annuity and life insurance claim processing.
Responsible for completing project work as assigned by management.
Projects include but are not limited to completing various monthly, quarterly and yearly reports.
Performs other duties as assigned.
Complies with all policies and standards.