Claims Examiner

About the Opportunity:

This role involves managing the claims process to ensure accurate assessment and timely resolution. The position supports the organization by evaluating claims, maintaining compliance, and improving operational efficiency.

Responsibilities:

• Evaluate incoming claims for eligibility, coverage, and validity
• Conduct investigations by reviewing medical records and relevant documentation
• Analyze policy provisions and contractual agreements to determine claim validity
• Use claims management systems to document findings and process claims
• Communicate with policyholders, beneficiaries, and healthcare providers about claim status and requirements
• Respond promptly to inquiries with professional and empathetic communication
• Address customer concerns and escalate complex issues to senior personnel as needed
• Ensure compliance with organizational policies, procedures, and regulatory requirements
• Maintain accurate records and documentation related to claims activities
• Follow guidelines for claims adjudication and payment authorization
• Identify opportunities for process improvement and efficiency within the claims department
• Participate in quality assurance initiatives to uphold service standards and improve practices
• Collaborate with team members and management to implement best practices and enhance performance
• Generate reports and analyze data on claims trends, processing times, and outcomes
• Contribute to management reports and presentations about claims operations

Key skills/competency:

• Claims processing
• Eligibility assessment
• Policy analysis
• Regulatory compliance
• Documentation
• Customer communication
• Process improvement
• Data analysis
• Investigation
• Claims adjudication