Claims Examiner II - Group Life

Reliance Matrix

3d • Hybrid

About The Position

The Life Claims Examiner II evaluates and processes lines of coverage handled in the Life Claims Department in accordance with applicable law and company guidelines, for claims of a greater complexity than those handled by Level I examiners. Claims may include Group Life, Accidental Death & Dismemberment, Voluntary Group Term Life, Voluntary All Risk, and Special Risk. The goal of the role is to consistently pay the accurate amount for each claim in accordance with the contract. This role also provides customer service that is respectful, prompt, concise, and accurate in an environment with competing demands.

Requirements

• High School Diploma or equivalent required.
• Minimum of two (2) years related claims experience required.
• Work experience in decision-making and information analysis.
• Requires excellent communication skills.
• Demonstrated prioritization and organization skills.
• Experience working in confidential/protected identification environments.
• Good math and calculation skills.
• Proficient in Microsoft Office products.
• Prior experience using an automated claim system required.

Nice To Haves

• Relevant Associates or Bachelor’s Degree highly preferred.
• HIAA, LOMA or ICA courses desirable.

Responsibilities

• Reviews and processes claim documents and proofs to verify eligibility based on contractual provisions and premium status within company guidelines and applicable law.
• Independently authorizes claim payments up to $125,000.
• Determines proper payee, verifies the accuracy of benefit amount calculations, and any applicable interest calculations and independently processes benefit payments up to $125,000.
• Processes system tasks and pending claims in accordance with department guidelines.
• Provides payment or denials promptly and in full compliance with department procedures and regulations.
• Participates in special projects and process improvements.
• Grant claim approval to Level I examiners for those claims that exceed their monetary approval authority.
• Completes special projects or other duties as assigned, which may require engaging in research, collaborating with out departments, and analyzing current business processes to improve quality control and efficiency.
• Develops an understanding and working knowledge of products, policies and contracts.
• Develops an understanding of the applicable contract/policy definitions of disability and relevant provisions, clauses, exclusions, as well as statutory requirements.
• Reviews medical and applicable information to verify eligibility.
• Determines proper payee, verifies the accuracy of benefit amount calculations, premium amount calculations under contributory plans, and any applicable interest calculations.
• Fully investigates all relevant claim issues.
• Provides clear, concise and accurate information to claimants as well as within the claims administrative system.
• Creates necessary correspondence for benefit denials, partial denials, or eligibility denials.
• Manages assigned case load as outlined in Key Measures.
• Requests any necessary additional information from the policyholder and medical providers, or vendors when needed.
• Utilizes most efficient means to obtain claim information.
• Provides customer service that is respectful, prompt, concise, and accurate in an environment with competing demands.
• Establishes, communicates, and manages claimant and policyholder expectations.
• Documents claim file actions and telephone conversations appropriately.

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.
• Volunteer days, community partnerships, and Employee Assistance Program
• Ability to connect with colleagues around the country through our Employee Resource Group program

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED