Medical Claims Consultant

AAA Life Insurance Company•Livonia, MI

16d•Hybrid

About The Position

Operating within the core values and operating principles of the organization, the Medical Claims Consultant is responsible for providing medical and business expertise and knowledge in support of claims decisions. This role’s primary responsibility is to serve as a resource to the claims team including contestable claims examiners, Accident and Health examiners, claims consultants and management with respect to denials, appeals, escalations or complex medical questions that arise in the processing of claims.

Requirements

Doctorate or Advanced healthcare degree (MD, DO, BA-PA (Physician Assistant Bachelor’s Degree in conjunction with PA certification), PA-C, NP, RN) with demonstrated claim-consulting or clinical review experience
Clinical experience (min 5-10 years) with a strong familiarity of a broad range of medical conditions, treatments or outcomes

Nice To Haves

Experience in the life insurance industry
Excellent ability to interpret and synthesize complex medical records, and to translate findings into actionable claims decisions.

Responsibilities

Serve as a resource to the contestable claims team. This includes review of contestable claims as needed by claims personnel.
Review of medical documentation including physician and hospital records, accident reports or other clinical materials
Review and understanding of policy language – interpret policy exclusions and endorsements in relation to medical findings
Review all contestable claim denials, including those that may have potential to result in litigation
Identify inconsistencies or gaps in medical documentation and recommend additional information when needed.
Serve as a resource to claims consultants and management with regards to denials, appeals or escalations that involve medical decisions
Resource to the entire claims team with respect to complex medical decisions that arise in the day-to-day handling of claims. Assist in determining whether a claim is eligible under policy language and with respect to any supporting medical documentation.
Provide training for claims examiners on medical topics relevant to claims decision making
Support claim work related to denials or appeals that require medical decision making
Participate in training and round tables, providing medical expertise in support of claims decision making.
Collaborates closely with claims examiners, underwriters, legal counsel and potentially third parties to ensure accurate and fair claims decisions
Maintain up-to-date knowledge of relevant medical standards, diagnostic/treatment guidelines, and regulatory/industry developments that impact claim adjudication