Claims Examiner II Supplemental Health

Reliance Matrix•Arizona, AZ

3d•$23 - $31

About The Position

The Supplemental Health Claims Examiner II evaluates and processes claims handled by the Supplemental Health Claims Department in accordance with applicable law and company guidelines. Claims may include Wellness, Accident, Critical Illness, and Hospital Indemnity benefits. The role aims to pay the accurate benefit amount under the contract while providing respectful, prompt, concise, and accurate customer service in an environment with competing demands. The examiner reviews claim documentation and proofs, verifies eligibility based on contractual provisions and premium status, and may authorize and process payments up to $10,000. The role also researches policy and contract provisions, reviews medical and other relevant information, investigates claim issues, manages an assigned caseload, requests additional information when needed, and communicates claim decisions to claimants and policyholders. The job requires maintaining accurate claim files and handling sensitive information appropriately. Work location may be flexible if approved by the Company. The expected hiring range is $23.24–$31.37 per hour, excluding other compensation components. Starting base pay depends on factors including work location, skills, experience, qualifications, and market conditions. Travel is not required.

Requirements

High school diploma or equivalent.
At least two years of related claims experience.
Work experience involving decision-making and information analysis.
Excellent communication skills.
Demonstrated prioritization and organization skills.
Experience working in confidential or protected identification environments.
Good math and calculation skills.
Proficiency in Microsoft Office products.
Prior experience using an automated claim system.
Ability to meet the stated physical requirements, with reasonable accommodation provided in accordance with applicable law.

Nice To Haves

Relevant associate or bachelor's degree highly preferred.
HIAA, LOMA, or ICA courses are desirable.

Responsibilities

Review and process Wellness, Accident, Critical Illness, and Hospital Indemnity claim documents and proofs to verify eligibility under contractual provisions, premium status, company guidelines, and applicable law.
Authorize claim payments up to $10,000; determine the proper payee; verify benefit calculations; and process benefit payments up to $10,000.
Process system tasks and pending claims in accordance with department guidelines.
Provide payment or denial decisions promptly and in compliance with department procedures and regulations.
Participate in special projects and process improvements.
Develop working knowledge of products, policies, contracts, disability definitions, relevant provisions, clauses, exclusions, and statutory requirements.
Review medical and other applicable information to verify eligibility and fully investigate relevant claim issues.
Verify premium calculations under contributory plans.
Provide clear, concise, and accurate information to claimants and in the claims administrative system.
Create correspondence for benefit denials, partial denials, or eligibility denials.
Manage assigned caseload in accordance with Key Measures.
Request necessary additional information from policyholders, medical providers, or vendors and use efficient methods to obtain claim information.
Provide respectful, prompt, concise, and accurate customer service.
Establish, communicate, and manage claimant and policyholder expectations.
Document claim file actions and telephone conversations appropriately.

Benefits

Annual performance bonus for all team members.
401(k) company match that is immediately vested.
Choice of three medical plans, including prescription drug coverage; company contribution to a Health Savings Account for High Deductible Health Plan enrollees.
Dental and vision coverage options.
Company-provided life and disability insurance.
Paid parental leave and adoption assistance.
Hybrid work arrangements for eligible roles.
Tuition reimbursement and continuing professional education.
At least 20 days of paid time off per year for new hires, plus nine company-paid holidays; PTO may increase with company level and years of service.
Volunteer days, community partnerships, and an Employee Assistance Program.
Employee Resource Group program.