Life & Health Claims Examiner

(Hybrid) Addison, TX

Hybrid work position for a Claims Examiner responsible for set-up and processing claims while providing exceptional quality service in a timely manner in an effort to build customer satisfaction and loyalty

Essential Functions

• Link and set-up Wellness and Physician consult claims in the work distribution system and policy administration system.
• Responsible for evaluating claims submitted, comparing the provisions of the policy and applicable laws with submitted information to accurately adjudicate the claim.
• Responsible for providing claimant necessary forms, instructions, reasonable assistance of information the claimant must provide for proof of claim.
• Types letters for request of medical and/or other necessary information relevant to the claim analysis.
• Responsible for timely requests, follow-ups and closeouts on claims submitted.
• Responsible for maintaining claim files up to standards with the Fair Claims Settlement Practice Regulations.
• Communicates with policyholders, beneficiaries, and/or health care providers concerning claim handling, claim denials, claim payments and policy contract provisions in a caring, courteous, empathetic, and professional manner.
• Process for payment, denial or request additional information for Wellness, Physician Consult benefits, group and substantive products.
• Existing knowledge of medical terminology, diseases, conditions and treatments applicable to our product lines.
• Process for payment, denial or request information for multiple substantive and group product maintaining satisfactory monthly performance rates
• Performs other duties as assigned.

Experience and Education

• 2 or more years’ claim experience in life/health claims or a related field
• High School Diploma or GED required.
• Bachelors’ degree preferred.

Job Requirements  

• Some LOMA or AHIP classes completed or a willingness to take the classes
• Ability to type 40 words per minute minimum
• Working knowledge of Microsoft Outlook, Word and Excel
• Strong written and verbal communication skills
• Ability to prioritize tasks
• Excellent organizational skills

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