Claims Examiner

Responsibilities & Duties:Claims Processing and Assessment:

• Evaluate incoming claims to determine eligibility, coverage, and validity.
• Conduct thorough investigations, including reviewing medical records and other relevant documentation.
• Analyze policy provisions and contractual agreements to assess claim validity.
• Utilize claims management systems to document findings and process claims efficiently.

Communication and Customer Service:

• Communicate effectively with policyholders, beneficiaries, and healthcare providers regarding claim status and requirements.
• Provide timely responses to inquiries and maintain professional and empathetic communication throughout the claims process.
• Address customer concerns and escalate complex issues to senior claims personnel or management as needed.

Compliance and Documentation:

• Ensure compliance with company policies, procedures, and regulatory requirements.
• Maintain accurate records and documentation related to claims activities.
• Follow established guidelines for claims adjudication and payment authorization.

Quality Assurance and Improvement:

• Identify opportunities for process improvement and efficiency within the claims department.
• Participate in quality assurance initiatives to uphold service standards and improve claim handling practices.
• Collaborate with team members and management to implement best practices and enhance overall departmental performance.

Reporting and Analysis:

• Generate reports and provide data analysis on claims trends, processing times, and outcomes.
• Contribute to the development of management reports and presentations regarding claims operations.