Claims Specialist
17 hours ago
Job Summary- To handle a limited case load of large and or complex life claims and serve as a referral resource for both Life Claims Technicians and Examiners, to ensure timely and equitable settlement and delivery of excellent customer service.- Job Accountabilities - Key Accountabilities- Ensure that claims processes and procedures meet state and federal regulatory requirements and that life claims decisions comply with known case law precedents.
- Conduct analysis into life claims activity and produce operational and analytical reports for management.
- Handle insurance department and consumer complaints.
- Work on cases where litigation is anticipated or outside counsel is directly involved in the resolution of a claims issue.
- Review and approve life, disability, critical illness and accelerated benefit payments up to a specified maximum for technicians, examiners & senior examiners.
- Review life claims involving complex, investigative considerations and assist examiners in managing complex cases.
- Evaluate life claims recommended for denial or where reconsideration of earlier action has been requested.
- Summarize pertinent issues and formulate final recommendation to management.
- Consult with Special Investigations Unit, Medical Director, Underwriting department, and Legal department on medical and legal issues related to life claims.
- Maintain record of legal precedents and changes in regulatory and statutory requirements.
- Communicate with Compliance, Law department and outside counsel on litigated claims.
- Assist in preparing responses to interrogatories, and production of documents.
- Assist in preparation of life claims statistical reports and newsletters for internal and field distribution.
- Conduct operational reviews for compliance and quality.
- Counsel with Life Claims staff on changes to practices and procedures in order to maintain compliance with regulatory and statutory changes, case law changes and best practices.
- Additional Job Functions- Ensure that internal quality control standards are met, operational controls are effective and conform to the Internal Control Framework.
- Directly oversee training in the department.
- Assist the Life Claims Supervisor in assessing the competence and capability of the examiner and technical staff.
- Business Accountabilities- Monitor and take responsibility for resources/cash, within defined procedures.
- Evaluate and assess costs and customer needs effectively to value and resolve cases within life claims authority limits.
- Identify and comply with the main principles relevant to legal and regulatory controls that govern standard work practices.
- Collect data from well-established sources and prepare reports including commentary and analysis trends to facilitate the resolution of life claims.
- Monitor life claims handling protocol/customer service charter in order to identify opportunities for improvement.
- Provide clear feedback to customers' enquiries and monitor specific issue handling and resolution.
- Resolve operational day-to-day problems referred from other functions of the business, ensuring an efficient and high-quality service is extended to all internal clients.
Job Qualifications- Required:
- Bachelors Degree and 6 or more years of experience in the Claims area
OR- High School Diploma or Equivalent and 8 or more years of experience in the Claims area
AND- 10 or more years of direct line claims management experience
Preferred:
- Strong verbal and communication skills
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