Claims Specialist

Blue Cross and Blue Shield of Kansas•Topeka, KS

1d•$27 - $34•Hybrid

About The Position

The AICK Claims Specialist will administer, review, and approve or deny all types of claims, for the products marketed by AICK, to include Waiver of Premium, Term Life, Accidental Death & Dismemberment, Short Term Disability, Long Term Disability, Living Benefit Rider, Ordinary Life, Yearly Renewable Term, all Voluntary Life and Accidental Death & Dismemberment coverage. This position also plays a part in helping develop new products, answering questions regarding how the provisions of a policy are administered and serving on Ad Hoc teams representing AICK as needed. This position is eligible to work hybrid or onsite in accordance with our Telecommuting Policy. Applicants must reside in Kansas or Missouri or be willing to relocate as a condition of employment.

Requirements

Ability to analyze detailed contract provisions and make decisions based on a set of facts or criteria.
Excellent written and verbal communication skills.
Extensive knowledge of ERISA/FICA regulations preferred.
High aptitude for math.
High school diploma or equivalent required.
Licensed Practical Nurse, Certified Nurses Aid or Certified Medical Aid license required
Minimum of 2 years experience in a professional, clinical, or as a medical office coordinator with billing experience required.
Minimum of 1 years’ experience working with Kansas Department of Insurance regulations for life and/or disability products preferred.
Ability to lift and carry up to 25 pounds.
Ability to stand or sit for extended periods.
Ability to look at a computer screen for prolonged periods.
Occasional walking, bending, or reaching within the office environment.
Ability to bend, kneel, stoop, or reach.
Ability to perform repetitive tasks.

Nice To Haves

Extensive knowledge of ERISA/FICA regulations preferred.
Minimum of 1 years’ experience working with Kansas Department of Insurance regulations for life and/or disability products preferred.

Responsibilities

Review, investigate, and adjudicate all claims (approval or denial) by verifying eligibility, coverage, and contract provisions, including obtaining additional information from employers, hospitals, reinsurers, and other external partners.
Ensure claim handling complies with all regulatory requirements, including ERISA, NAIC unfair claims practices, and applicable state regulations, and that claims are processed within statutory timeframes with appropriate documentation.
Interpret and apply policy provisions, reinsurance treaties, and group contracts to determine claim payability, reinsurer liability, and continuation of liability; partner with reinsurers to confirm determinations.
Conduct in-depth investigations on complex or questionable claims, including coordinating with investigators or rehabilitation specialists and preparing documentation for potential legal proceedings when required.
Manage disability claims lifecycle, including review and processing of continuance requests, evaluation of treatment plans, and assessment of rehabilitation or return-to-work options.
Communicate claim decisions and policy provisions clearly to claimants, employers, attorneys, and regulatory bodies via phone and written correspondence, including responses to denials and inquiries.
Manage overpayment recoveries and collections, including establishing and monitoring repayment arrangements with claimants.
Maintain accuracy of claim accounts and systems by verifying reports, reconciling balances, making necessary adjustments, and approving claims for payment per guidelines.
Research and respond to State Insurance Department complaints, implement corrective actions as needed, and maintain required complaint logs in compliance with regulatory standards.
Support contract updates and product development initiatives by collaborating across departments, participating in Ad Hoc teams, and identifying operational or compliance improvement opportunities.
Compile and report required financial and operational data, including Schedule F for the Annual Statement, management reports (e.g., claim processing time, paid claims, closed claims), and other required reporting (FICA, W-2/W-3).
Participate in system testing for claims payment platforms, including validation of new releases and defect fixes.