This position is responsible for examining routine and non-routine claims for one or more products and multiple series of contracts by evaluating the extent of liability within established guidelines. This position is accountable for analyzing claims to determine benefit/contract eligibility and processing claim transactions within specified dollars limits in compliance with state and federal regulatory standards, and NAIC (National Association of Insurance Commissioners) guidelines. Additionally, this position is a member of a team, actively partners with peers on meeting established service and quality standards, provides coaching and training to other Examiners and identifies opportunities for process improvements.

REQUIRED JOB QUALIFICATIONS

• High school required. College degree preferred.
• Minimum of 2 years relevant experience.
• Professional credentials preferred (e.g. LOMA, ICA).
• Intermediate knowledge of claim administration and operations as well as pertinent laws and regulations.Must possess strong interpersonal skills, as well as excellent verbal and written communication skills.

• Determine extent of liability on routine and non-routine claims and make final claim decisions within specified dollar limits. Contribute to accurate fraud detection and reporting by referring suspected fraud to appropriate staff for review according to established procedures.
• Analyze claim transactions and process payments utilizing various work flow, administrative, and LOB (Line of Business) systems, accurately and cost effectively according to contract provisions and in compliance with internal service and state and federal regulatory standards.
• Ensure high level of customer satisfaction by partnering with members, financial associates, doctors, providers, attorneys, police, vendors and other internal and external customers regarding claims, settlements and interpretation of policy provisions, which may include highly confidential information or complaints, often educating the recipient on products/benefits and regulatory requirements.
• Handle sensitive written and verbal communications. May be called upon to influence behavior via these communications.
• Actively participate in the development and implementation of business processes, standard operating procedures, documentation and other support materials required for unit operation. May also analyze data and offer remediation in response to audit inquiries or compliance examinations as determined by the Claims Consultant.Provide consultation to Associate Claims Examiners in helping to answer questions and make decisions on claims with a moderate level of complexity.