Claims Auditor

Claims Auditor

Job Summary : Review, analyze, investigate, and authorize payment of benefits within authority guidelines and in accordance with the established guidelines and terms of the policy/contract.


Essential Responsibilities:

• Analyze and evaluate claim/benefit request forms and documents to determine eligibility based on policy/contract provisions. Based on evaluation of information received determine to pay, deny or require additional information to make payment determination.
• Enter claims data into claim administrative system and document relevant information.
• Compose correspondence to banks, agents, lawyers, hospitals, doctors, claimants/protected, or beneficiaries on payment determination or to obtain additional or missing information to make determination. Utilize standardized letters in routine cases; modify as needed.
• Correspond and answer phone calls from insureds, beneficiaries, banks, doctor's offices, agents, or attorneys regarding submitted claims/benefit requests, status, and policy/contract provisions. Document discussions on claim system.
• Perform claim reviews of medical information and accuracy of the application to determine if eligibility requirements were met at time of issue. Also, make the determination whether any of the policy/contract exclusions apply. Refer cases of undisclosed health history to legal for further review. If it is determined misrepresentation of health history occurred that would impact coverage eligibility, then handle the request appropriately.
• Review life claims to assure the correct beneficiary has made claim for the proceeds. Review the beneficiary designated and determine if the beneficiary is eligible for payment.
• At time of payment of a life claim, review state requirements to determine if required to perform a data match of beneficiaries against a Child Support Division database in attempt to intercept payments to a parent who may be in default of child support obligations.
• Identify and document potential cases of fraud and refer file to Legal department for determination of fraudulent activity.
• Provide support to home office sales force and accounts with claim/benefit requests questions and status concerns and to ensure consistent communication.
• Follow-up on pending claims/benefit requests and information requested.
• Stay abreast of state requirements and industry changes. Also requires knowledge of all protection options offered and available through our Credit Union accounts.
• Assist with special projects and duties as assigned including backup and coverage for other areas.
• Interact with other department members to resolve problems and inquiries and to allow for efficient data and information flow.
• Perform other related duties as assigned.

Required Education and Experience:

• Associates Degree in Business, or other complimentary discipline, or equivalent experience.
• Five years of claim auditing experience, with progressively responsible levels of duties and accountabilities. months previous work experience.
• Customer service experience requiring resolutions of issues.
• Solid computer skills, working with various software packages to retrieve and document information.
• Exceptional verbal and written communication skills. Ability to interact effectively and professionally with both internal coworkers and external contacts. Strong attention to detail and organizational abilities.

Preferred Education and Experience:

• Attainment of professional insurance designations or other insurance designations preferred.
• Medical terminology course and industry courses such as Health Insurance Association of American (HIAA), ICA, and LOMA helpful.
• Previous experience within credit insurance or life claims preferred.
• Customer service experience in environments requiring resolution of sensitive matters.

Position Type and Expected Hours of Work:

This is a full-time position. CSO's overall business workdays are Monday through Friday, 7:30 a.m. to 5:00 p.m. with the incumbent's actual work hour schedule to be determined by their supervisor. Attendance is required with employee working their scheduled hours of work at the employee's designated work location, which may be office or remote based, or a combination thereof.


Work Environment:

This job operates in a corporate office environment. Incumbent is expected to reasonably work through necessary stressors of the job and work well with others.


It is CSO's practice to communicate pertinent information on job duties, company policies and benefit disclosures via its email system. Thus, employees are required to access their company email account as an integral part of their job responsibilities.


Physical Demands:

This role routinely uses standard office equipment such as computers, cell phone, laptops, photocopies, filing cabinets.


The work performed is sedentary with the employee seated, and standing intermittently, to perform most duties. Less than 10% of the time will be spent performing physical activities and the job does not involve stooping, crawling or kneeling except in occasional situations. However, a negligible amount of lifting, pulling and pushing may be required to perform the work and some walking, standing, and manual dexterity may be required in routine activities such as carrying papers, opening file drawers, operating basic office equipment.

Travel:

This position requires no overnight travel.

The above job description has been designed to indicate the general nature of work performed; the level of knowledge and skills typically required; and usual working conditions of this position. It is not designed to contain, or be interpreted as a comprehensive listing of all requirements or responsibilities that may be required by employees in this position.

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

CSO is a smoke and drug free workplace and requires post offer drug testing. Those applicants in need of reasonable accommodations to the application, the hiring process or the position applied, should communicate the request to Human Resources at View phone number on click.appcast.io, toll-free at View phone number on click.appcast.io.

Job offers are contingent upon the successful completion of our post-offer drug screen and a background check which includes criminal, education, and past employment. Some positions may also include credit and/or motor vehicle report where those checks are related to the position. Criminal convictions do not necessarily prevent employment. Various factors may be considered including, but not limited to, the type of conviction and its relationship to the job, the nature and seriousness of any offense and the length of time since conviction. Applicants are not obligated to disclose any sealed criminal record.

Equal Opportunity Employer

Participates in E-Verify