Group Claims Examiner

📋 Description

• Oversee and manage claims related to Life, Disability, and Waiver of Premium, ensuring adherence to company policies and regulatory guidelines.

• Assess waiting periods, confirm medical providers and treatment facilities, and evaluate fee reasonableness.

• Establish claim applicability, carry out investigations, and analyze allowable benefits as per policies or certificates.

• Authorize claims within designated authority limits, referring complex or high-value claims when necessary.

• Precisely input and manage claims data in the claims management system.

• Collect and verify documentation to guarantee prompt and accurate claim processing.

• Perform thorough reviews to confirm claim accuracy and detect discrepancies or potential fraudulent activities.

• Deliver timely, courteous, and professional service to clients, employers, broker partners, and internal stakeholders.

• Effectively communicate with claimants and beneficiaries to address inquiries and ensure clarity throughout the claims process.

• Maintain organized, audit-ready claim files that promote transparency and compliance.

• Collaborate with legal, compliance, underwriting, and SIU teams on complex, disputed, or potentially fraudulent claims.

• Ensure compliance with all regulatory standards, company policies, and service expectations.

• Support a uniform and compliant claims handling methodology across all business lines.

• Analyze claims data to uncover trends, patterns, and areas for enhancement.

• Create reports and summaries for leadership to facilitate data-driven decision-making.

• Collaborate with internal teams to refine workflows, decrease cycle times, and improve claim results.

• Assist in the implementation of new tools, systems, and best practices to boost efficiency and client satisfaction.

• Stay updated on industry regulations, product developments, and compliance obligations.

⛳️ Requirements

• High School Diploma or GED is mandatory.

• A Bachelor’s degree in a related field or equivalent experience is preferred.

• 2–4 years of experience in group insurance claims processing or a related financial services role.

• Strong knowledge of insurance policies, claims processes, and regulatory standards.

• Proficiency in claims management systems and Microsoft Office applications.

• Exceptional analytical, problem-solving, and decision-making abilities.

• Keen attention to detail and capability to handle multiple priorities in a fast-paced setting.

• Effective written and verbal communication skills.

• Dedication to continuous learning and professional growth.

🏝️ Benefits

• Standard office environment.

• Occasional travel may be necessary.