Job Summary:

This position is responsible for analyzing and processing insurance claims to determine the extent of the insurance carrier’s liability in a manner that supports the mission, values and standards of the Company. Primary responsibilities include efficient adjudication of insurance claims, both phone and written communication with insureds, travel suppliers, medical facilities and others, as well as maintaining all state Department of Insurance regulations for claims files. Weekends may be required. This position reports to the Claims Supervisor.

Principal Duties and Responsibilities:

Claims Processing and Coordination

Process all claims assigned in a timely, efficient, and accurate manner ensuring that all appropriate policies, procedures and standard best practices are being followed
Review information on claim forms, Physician Statement and other documentation to ascertain completeness and validity of claim
Correspond with insureds, physicians, agents and other appropriate parties in order to obtain proper documentation and to finalize claim
Maintain proper reserves on each claim file
Ensure that proper file documentation is collected and maintained, including all records of correspondence and telephone conversations
Investigate claims and direct the activities of outside adjusters and investigators
Issue denial of benefits letters when appropriate
Process attorney represented claims files
Review and respond to Department of Insurance complaint letters
Respond to written and phone inquiries regarding claims status
Issue payments in a timely and accurate manner
Ensure that current Federal and State insurance claims regulations, laws, and best practices are being employed consistently for all jurisdictions

Customer Service

Answer questions and respond to inquiries from internal and external customers regarding coverage issues and general policy information

Teamwork and Department Support

Assist in the mentoring and training of other employees as directed
Perform other duties or special projects as assigned by management team

Required / Desired Knowledge, Experiences and Skills:

Exceptional communication, problem-solving, and organizational skills
Strong reading, writing, comprehension and proofreading skills
Knowledge of standard concepts, practices, regulations, and laws within insurance field preferred
Bilingual English/Spanish language fluency – verbal, reading, and writing skills, is a plus

Education/Certifications:

High School Diploma or equivalent required; Bachelor’s degree (B.A.) from an accredited institution a plus
Previous claims and customer service experience is highly preferred

Physical Working Environment:

While performing the duties of this job, the employee is required to stand; walk; sit for long periods of time; use of hands to grasp, handle, or feel; reach with hands and arms; finger dexterity; talk; hear. The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl. The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus.

The above statements are intended to describe the general nature of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties and skills required of employees so classified.

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Claims Representative

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