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Claims Representative

POSITION 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 under the direction of the Claims Department Manager.

 

EDUCATION AND EXPERIENCE

  • 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;

 

KNOWLEDGE 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.

 

KEY POSITION RESPONSIBILITIES (other duties may be assigned): 

Claims Processing and Coordination

  • Process all claims assigned in a timely, efficient and accurate manner ensuring that appropriate all 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.
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