Claims Examiner Trainee

Job Summary

Under the direct guidance of a Supervisor or Senior Examiner, the Examiner Trainee learns to analyze claims to determine if benefits are due based on established procedures and industry best practices. As directed, the Examiner Trainee investigates claims through the gathering and processing of information from policyowners, physicians and third parties to help ensure the appropriate decision is reached.

Primary Responsibilities

• Review an assigned caseload of claims and determine benefits due pursuant to the policy provisions within a designated authority level
• Refer claim activity outside authority level to Senior Examiner or Supervisor
• Discuss claims decisions regularly with Senior Examiner or Supervisor
• Make timely claims payments through the prompt and continual follow up of outstanding claim information as approved
• Professionally and effectively communicate claim action with the claimant and all other appropriate parties, as directed
• Properly escalate difficult or complex claims or claimant situations as necessary
• Properly document all claim decisions through relevant information such as claim forms, medical records, independent medical exams and investigations
• Accurately process payments through our information systems with the utmost attention to detail
• Adhere to all claim rules, regulations and laws
• Develop and maintain superior customer service to all of our customers, both internally and externally, through prompt and courteous service communication
• Attend meetings and educational seminars or conferences for professional development as approved by management
• Learn about the insurance industry, the Company, its products, services, claims processing and the expectations of the position
• Develop skill base to apply discretion and sound judgment to various claims
• Assume additional responsibilities as necessary

Qualifications

• Bachelor’s degree* required – preferably in Insurance, Risk Management, Business, Accounting, Finance or other similar discipline.
• Demonstrate reliability, integrity and professionalism as well as a positive attitude
• Must handle Protected Health Information and maintain confidentiality at all levels
• Highly self-motivated, organized and attentive to details
• Effective communication skills, both verbal and written
• Excellent problem solving skills; able to respond to requests promptly and proactively
• Comfortable in fast-paced environment; self-directed and flexible
• Ability to maintain professional and constructive working relationships with others as well as work independently
• Strong customer service and quality/accuracy focus
• Proficiency of related information systems, including Microsoft Office programs (Word, Excel, Outlook)
• Bilingual (Spanish) proficiency a plus

*College or university must be sufficiently accredited and listed in the U.S. Department of Education Accreditation Directory.