Claims Examiner - TPA

WHAT WE'RE LOOKING FOR

The primary responsibility of the Claims Examiner is to process incoming claims for his or her assigned insurance programs and to become an expert on each school's benefits, provider health services networks, and procedures that are unique to each program. It is critical that each examiner places emphasis on accuracy, customer service, and accountability of their work. The examiner is also responsible for serving as the claims representative for school administrators.

A GLIMPSE INTO YOUR DAY

• Manages and prioritizes workload to be in compliance with the Company's commitments to their clients.
• Reviews claims, researches insured/claimant's records to identify any third-party liability and approves or denies payment as appropriate.
• Adjudicates claims using Company guidelines and the carrier/school benefit schedules, including the utilization of re-pricing networks, UCR values, etc.
• Requests additional information to validate claims from providers, insured/claimants, and schools/colleges, verifies claim calculation.
• Documents files and records of pending actions.
• Identifies and notifies appropriate Company officials of problems with the claims system.
• Reviews production, benchmarks and errors with supervisor periodically.
• Meets or exceeds accuracy and production level standards.
• Provides customer service and serves by answering incoming calls when applicable from insureds, providers, and school representatives. Assists with claims issues, claims status and benefits.
• If applicable, handles foreign language calls using company LAP (Language Assistance Program) procedures.
• Initiates calls to ascertain the validity of a claim or to gather additional information in order to process or deny claims.
• Responds to Auditor findings in a timely manner.
• Generates letters to insureds and providers as appropriate.
• Performs other projects, duties, and tasks, as assigned.

WHAT SUCCESS LOOKS LIKE IN THIS ROLE

• High school diploma or its equivalent.
• College degree preferred or comparable work experience.
• 1+ years' medical health claims experience preferred.
• Ability to read, analyze and interpret company guidelines and benefit documentation, or government regulations.
• Ability to calculate figures and amounts such as discounts, interest and percentages.
• Intermediate personal computer skills including electronic mail, routine database activity, word processing, spreadsheets, etc.
• Self-managed and responsible time management.
• Customer focused, high integrity, excellent work ethic.
• Willingness to adhere to all principles of confidentiality.
• Must value operating in a collaborative work environment.
• Ability to handle multiple tasks simultaneously.
• Working knowledge of the laws and regulations associated with HIPAA.

WHY CHOOSE RELATION?

• Competitive pay.
• A safe and healthy work environment provided by our robust benefit program including family health and wellness programs, 401K, employee assistance programs, paid time off, paid holidays and more.
• Career advancement and development opportunities.

#LI-MP1

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Note: The above is not all encompassing of the full position description.

Relation Insurance Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

The wage range for this role takes into account the wide range of factors that are considered in making compensation decisions including but not limited to skill sets; experience and training; licensure and certifications; and other business and organizational needs. The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the position may be filled. At Relation, it is not typical for an individual to be hired at or near the top of the range for their role and compensation decisions are dependent on the facts and circumstances of each case. A reasonable estimate of the current range is presented within this posting.

You may also be eligible to participate in a discretionary annual incentive program, subject to the rules governing the program, whereby an award, if any, depends on various factors, including, without limitation, individual and organizational performance.

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$35,000.00 - $54,000.00