Supplemental Health Claims Examiner

Role Description

The Claims Examiner is responsible for accurate and timely adjudication of complex professional, facility, and ancillary claims. This role makes timely, accurate, and customer-focused claim decisions for supplemental health products that may include critical illness, hospital indemnity, and scheduled or group accident claims.

• Proactively reach out to internal and external sources to gather relevant medical, financial, legal, and/or general data.
• Compare gathered information to the applicable contract and procedural documents.
• Conduct analysis and engage peers and management as appropriate.
• Communicate verbally and in writing, leveraging the claim system with accurate and comprehensive information.
• Maintain performance within departmental metrics.

Qualifications

• 1-3 years of cumulative, relevant experience.
• Extensive knowledge of supplemental health products and the ability to interpret policy language for critical illness, hospital indemnity, and scheduled or group accident claims.
• Proficient in reviewing medical records, itemized bills, and standard claim forms such as the UB‑04 and HCFA 1500.
• Exercises initiative and independent judgment while working within established procedural guidelines.
• High school diploma required.

Requirements

• Make timely, accurate, and customer-focused claim decisions.
• Reach out to obtain relevant information from multiple sources as needed on a claim-by-claim basis.
• Review medical records, itemized bills, and adjudicate benefits for one claimant with multiple lines of coverage.
• Compare the information received to the terms, limitations, and conditions of the contract and applicable procedural documents.
• Document the claim systems accurately and comprehensively while maintaining efficiency.
• Prepare and disseminate articulate written and verbal communication to assorted internal and external sources.
• Prepare, update, and utilize a claim management plan to attain the most appropriate outcome.
• Remain in full compliance with ERISA, HIPAA, Fair Claim Settlement Practices Acts, and other statutory regulations.
• Demonstrate proficiency in supplemental health products and claim administration techniques.
• Maintain a superior level of genuine caring and empathetic customer service throughout all interactions.
• Quickly resolve issues or concerns with payments, voids, and refunds.
• Work as a team to support one another through flexibility, collaboration, and professionalism.

Benefits

• Flexible full-time or hybrid telecommuting arrangements.
• 401(k) plan with immediate vesting and company matching up to 6%.
• Paid time away including vacation and sick time, flex days, and ten paid holidays.
• Community involvement with company matching for donations.

Company Description

Symetra is a national financial services company dedicated to helping people achieve their financial goals and feel confident about the future. We are guided by the principles of Value, Transparency, and Sustainability.

• We provide products and services people need at a competitive price.
• We communicate clearly and openly so people understand what they're buying.
• We design products and operate our company to stand the test of time.
• We are committed to diversity, equity, and inclusion (DEI).