Claims Examiner II

SWBC•San Antonio, TX

34d

About The Position

SWBC is seeking a talented individual to review and evaluate incoming claims for payment or denial and acts as a liaison for the carrier and the financial institution. Why you'll love this role: This role allows you to help those who are dealing with difficult circumstances in their lives. Your help gives them a sense of relief in times of need. You will also have a team who is supportive and there to help at any time.

Requirements

High School Diploma or equivalency.
Minimum one (1) year of claims processing or related experience.
Able to type at least 40 WPM accurately and know 10 key by touch.
Working knowledge of word processing and spreadsheets preferably in Microsoft Word and Excel.
Excellent organizational and interpersonal skills.
Able to draft business letters.
Able to read and understand medical records.
Able to prioritize job duties and be detail oriented.
Able to lift up to 10-20 lbs. of claim storage boxes.
Able to move (push/pull) up to 50 lbs. of files and documents.
Able to bend, stoop, and stand to perform filing duties.

Nice To Haves

Some college course work in medical terminology or related field preferred.

Responsibilities

Adjudicates routine to moderately complicated Payment Protection claims and determines if benefits are payable or not; ensures claims are adjudicated within the customer service level standards established by the company with adherence to Prompt Payment of Claims Regulation respective to each state.
Prepares letters and requests any information needed to make a determination on claims from insurance carrier, family, claimant, physicians, employers, and others.
Submits all claims determined contestable to carriers for review and final determination.
Calculates the benefit amount and ensures claims are not being overpaid or underpaid according to the provisions within the specific insurance certificate/policy form that describes the terms and conditions of the applicable coverage.
Assists claimants or financial institutions via phone to answer questions, and documents such within the claim file.
Maintains carrier guidance and administrative files, required logs to comply with carrier requirements, reviews and evaluates instructions provided by carriers and assists management with proper implementation.
Completes request for refund form and submits to Premium Processing; verifies monthly outstanding loan balances for active and inactive financial institutions; and ensures that open accounts loan balances are verified every 6 months and closed accounts are verified each month; provides back-up assistance to the claims processor position for establishment and set-up of new claims.