Claims Examiner

Jacksonville, Florida
Not Specified
Jun 22, 2022
Jul 22, 2022

Claims Examiner - Jacksonville, FL

Job Summary:

Primarily responsible for adjudicating, pending, investigating and/or denying claims by verifying submitted
information against medical records, coverage issued, employer statements, and creditor information.
Provides professional customer service to insureds, agents, and accounts. Enforces contractual
requirements impartially and expeditiously. May identify claims of a potentially fraudulent nature and refer
to management for review. Meets the demands of a production environment and adheres to established
service standards.

Minimum Qualifications:

High School Diploma or equivalent required.
• 2-4 years of experience on PC or CRT.
• 1-2 years' experience with Credit Insurance claims and/or other related
claims processes.
• Knowledge of and experience with medical terminology and AS/400
system experience preferred.
• Credit Insurance, A&H claims and Customer Service training preferred.
• Bilingual skills are a plus.

Primary Job Functions:

• Reviews claims and determines appropriate actions, such as; pay, request additional information,
or deny benefits based on the type of coverage, policy provisions and exclusions as defined in the
insurance certificate, including endorsement(s) and master policy.
• Ensures that all required documentation for claim(s) has been submitted and verified.
• Enters current claim information into the computer system and verifies that existing information
related to the claim and the insured is accurate.
• Executes net pay program to calculate claim liability and works with accounting to request manual
checks for claims that are adjudicated manually.
• Communicates with insureds, agents, outside vendors, medical providers and accounts verbally
and in writing to gather or provide information about claims.
• Identifies potential workflow improvements and impediments.
• Analyzes information and makes payment or adjustments as needed.
• Maintains an understanding of related state laws, anti-fraud compliance requirements, claim
processes, fair claim practice and company guidelines.
• Meets or exceeds quality and production standards and maintains all claims within predetermined service level standards.

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