Claims Examiner II - Absence Management Specialist
About The Position
The Claims Examiner will act as a liaison between client, employee and healthcare provider. In this position, you are responsible for applying appropriate claims management by providing reliable and responsive service to claimants and clients. Description of responsibilities: Investigates claim issues providing resolution within departmental and regulatory guidelines. Interprets and administers contract provisions: eligibility and duration Accurately codes all system fields with correct financial, diagnosis and duration information. Coordinates with other departments to ensure appropriate claims transition or facilitate timely return to work. Adheres to compliance, departmental procedures, and Unfair Claims Practice regulations. Makes determinations to approve, deny or delay and or reach out to additional resources for review, based on medical certification review and management. Determines the duration associated with the leave and or disability based on the information given by the healthcare provider. Process medium to high complexity or technically difficult claims. Develops and manages claims thought well developed action plans; continues to work the action plan to bring the claim to an appropriate and timely resolution. Actively contributes to customer service, quality and performance objectives. Proactively engages in departmental training to remain current with all claim management practices. Responsible for managing Performance Guarantee clients and meet targeted metrics. Responsible and accountable for maintaining and protecting personal health information. Must maintain a high level of confidentiality and abide by HIPPA rules and regulations.
Requirements
- High School Diploma or GED (Bachelor’s preferred)
- Ability to develop proficiency regarding required RSL products, systems and processes related to the effective delivery of new business proposals
- Microsoft Office experience
- Attention to detail, analytical skills, and the ability to collaborate with others and work independently
- Strong organizational skills, including the ability to prioritize work and multi-task
- Customer service experience and orientation
- Written and verbal communication skills
Nice To Haves
- Bachelor’s preferred
Responsibilities
- Investigates claim issues providing resolution within departmental and regulatory guidelines.
- Interprets and administers contract provisions: eligibility and duration
- Accurately codes all system fields with correct financial, diagnosis and duration information.
- Coordinates with other departments to ensure appropriate claims transition or facilitate timely return to work.
- Adheres to compliance, departmental procedures, and Unfair Claims Practice regulations.
- Makes determinations to approve, deny or delay and or reach out to additional resources for review, based on medical certification review and management.
- Determines the duration associated with the leave and or disability based on the information given by the healthcare provider.
- Process medium to high complexity or technically difficult claims.
- Develops and manages claims thought well developed action plans; continues to work the action plan to bring the claim to an appropriate and timely resolution.
- Actively contributes to customer service, quality and performance objectives.
- Proactively engages in departmental training to remain current with all claim management practices.
- Responsible for managing Performance Guarantee clients and meet targeted metrics.
- Responsible and accountable for maintaining and protecting personal health information.
- Must maintain a high level of confidentiality and abide by HIPPA rules and regulations.
Benefits
- An annual performance bonus for all team members
- Generous 401(k) company match that is immediately vested
- A choice of three medical plans (that include prescription drug coverage) to suit your unique needs.
- For High Deductible Health Plan enrollees, a company contribution to your Health Savings Account
- Multiple options for dental and vision coverage
- Company provided Life & Disability Insurance to ensure financial protection when you need it most
- Family friendly benefits including Paid Parental Leave & Adoption Assistance
- Hybrid work arrangements for eligible roles
- Tuition Reimbursement and Continuing Professional Education
- Paid Time Off – new hires start with at least 20 days of PTO per year in addition to nine company paid holidays. As you grow with us, your PTO may increase based on your level within the company and years of service.
- Volunteer days, community partnerships, and Employee Assistance Program
- Ability to connect with colleagues around the country through our Employee Resource Group program
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
Number of Employees
1,001-5,000 employees
