Claim Examiner

Claim Examiner

The Claim Examiner is responsible for managing, investigating, and processing Accident & Health insurance claims. The ideal candidate should be highly detail-oriented, precise, and able to follow and interpret guidelines and requirements.

Essential Duties & Functions

Reasonable accommodations may be made to enable individuals to perform the essential functions.

• Demonstrate fundamentally sound claim handling by achieving compliance in the areas of investigation, coverage and processing of claims
• Timely and appropriately communicate with the claimant and client, as well as internally
• Establish proof of loss by reviewing medical documentation; assembling additional information as required from outside sources; including claimant, client, provider, and other insurance companies
• Calculates and pays benefits due; approves and makes timely claim payments and adjustments
• Ensure legal compliance by following company policies, procedures, guidelines, as well as state and federal insurance regulations
• Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims for our clients
• Recognize and properly address coverage issues, potential fraud, and subrogation
• Ensure claim files are properly documented through internal notes and correspondence logs, and claim coding is correct
• Refers cases as appropriate to Manager

Job Skills

• Team Player
• Excellent verbal and written communication
• Prioritize tasks appropriately and maintain organization
• Advanced critical thinking and problem-solving skills
• Strong decision-making ability and sound judgement
• Build client relationships
• Self-starter and self-disciplined in accomplishing tasks
• Ability to work unsupervised
• Willingness to obtain Insurance Adjuster License

Job Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Required/Preferred Education and Experience

Required Education: Bachelor's Degree or Equivalent Experience

Preferred Experience: 1-3 years insurance experience, medical billing or coding experience

Preferred Licensure: Accident & Health Adjuster License

Position Type and Expected Hours of Work

This is a full-time position. The role is open to candidates who are in a fully remote, hybrid, or on-site role. One full week of on-site training is required at the start of employment. Days and hours of work are Monday through Friday, 8:30 a.m. to 5 p.m. The schedule for this role can be contingent upon Supervisor and Human Resources approval. Some evening and weekend work may be required.

Travel

Limited travel would be encouraged for trainings or team meetings. This would be discussed ahead of time and agreed upon between both Supervisor and employee.

EEO Statement

A-G is committed to the principles of equal employment. We are committed to complying with all federal, state, and local laws providing equal employment opportunities, and all other employment laws and regulations. It is our intent to maintain a work environment that is free of harassment, discrimination, or retaliation based on the following protected classes: age (40 and older), race, color, national origin, ancestry, religion, sex, sexual orientation (including transgender status, gender identity or expression), pregnancy (including childbirth, lactation, and related medical conditions), physical or mental disability, genetic information (including testing and characteristics), veteran status, uniformed servicemember status, or any other status protected by federal, state, or local laws. A-G is dedicated to the fulfillment of this policy in regard to all aspects of employment, including, but not limited to, recruiting, hiring, placement, transfer, training, promotion, rates of pay, other compensation, termination, and all other terms, conditions, and privileges of employment. A-G will conduct a prompt and thorough investigation of all allegations of discrimination, harassment, or retaliation, or any violation of the Equal Employment Opportunity Policy in a confidential manner. A-G will take appropriate corrective action, if and where warranted. A-G prohibits retaliation against team members who provide information about, complain about, or assist in the investigation of any complaint of discrimination or violation of the Equal Employment Opportunity Policy.

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.