Critical Illness Claims Rep

Critical Illness Claims Rep

Responsible for interpreting contract language and processing claims with high complexity. Provide a high quality of service with minimal direction, that is consistent with regulatory and compliance requirements.

Description

• Analyze and determine Critical Illness claim processing in an accurate and timely manner, to include payment, denial, and requests for additional information.
• Create and maintain excellent working relationships and communication with internal and external customers.
• Actively participates in root cause problem-solving activities in a team environment.
• Manage work queue assignments within agreed SLAs, and support others in the same.
• Ability to handle complex claims including communicating with customers by phone and providing empathy and de-escalating measures for sensitive issues.
• Other duties and projects as assigned.

Knowledge & Experience

• Experience with Voluntary Critical Illness Insurance benefits preferred with complex medical review experience.
• Strong ability to decipher medical terminology and documentation to connect with Policy definitions to determine if all conditions of the benefit are met.
• Interpret diagnoses and clinical evidence within medical records to determine when an individual was diagnosed with their condition(s).
• Reduce risk through attention to detail to maintain compliance guidelines and ensure decisions are fully supported by documentation and policy language.
• Strong written and oral communication capabilities to provide clear, policy-based denial letters to our customers.
• Understand Standards of Work and job aids.
• Advanced technical proficiency with claims processing systems and the ability to navigate multiple systems concurrently to research, validate, and adjudicate claims efficiently.
• Strong working knowledge of Microsoft Office applications (Excel, Word, Outlook).
• Proven critical thinking and problem solving.
• Capacity to prioritize and balance workloads in a workflow environment.
• Ability to collaborate with others, to include across departments, to solution for shared customers.

TALENT Software Services