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Requisition Number: 257 Job Title: Claims Examiner Area of Interest: Customer Service & Claims
City: Carmel
State / Province: Indiana
External Description: Under limited Supervision, adjudicate routine home and facility-based claims for LTC products, fairly and equitably within the contract parameters, and provide quality service to providers, agents, clients, and families.· Adjudicates routine home and facility based claims for LTC products. Interprets and applies fundamental policy language to claim scenarios. .· Performs investigation and research on standard claims, including obtaining proof of loss. Escalates cases that are in need of investigation. Queries medical and service providers to obtain licensure information and proof of loss.· Reviews claimant’s diagnosis. Verifies the provider of care is appropriate and in accordance with contract language and government regulations regarding healthcare providers.· Applies knowledge concerning state and federal regulations of the health-care industry, government-funded programs, and private insurance.· Communicates with service providers regarding claim circumstances, including policy language and options available to the client. Handles consumer inquiries.· AssistClaim Contact Centerwith Customer calls regarding claim benefits.· Work standard operation reporting as needed. · Communicates with Sr. Examiners and management on cases with special handling of non-routine claim situation.· Determines benefit eligibility amounts based on policy language and internal procedures.· Make suggestions to improve departmental workflow, processes and procedures.Other duties as assigned. Requirements: Job Requirements: · Demonstrated knowledge of medical terminology and/or LTC insurance products.· Knowledge of insurance regulations and industry standards.· Knowledge of Microsoft software packages.· Strong knowledge of medical provider settings and geriatric care.· Excellent verbal and written communication skills and customer service skills. Must be able to create and write business letters.· Excellent interpersonal skills· Ability to investigate and research claims.· Ability to perform benefit calculations.· Detailed oriented · Demonstrated ability in telephone skills, including experience in telephonic counseling or customer service· Knowledge of long term care service delivery system, familiarity with the aging process and medical problems of the elderly, and experience with older persons preferred· Ability to handle sensitive medical and socio-emotional information· Detail oriented, strong organizational skills, creative problem-solving skills· Customer focused toward internal and external clients· Knowledge of basic office procedures· Flexible with the ability to work on multiple tasks· Ability to meet predetermined deadlines· Ability to work in a Windows environment with Microsoft Office products including Outlook, Word, Excel, and Access
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