Sr. Claim Examiner

Position Overview

The Sr. Group Claims Examiner, analyzes high dollar claims and determines eligibility of Group Reinsurance claims. Establishes, monitors and updates system with appropriate reserves or reserve assumptions.

Identifies claim and underwriting issues that might affect the claims process or administrative services.

Responsibilities

Under supervision, analyzes and determines eligibility of Group Reinsurance Medical or Managed Care claims; interprets and verifies that the reinsurance claim was properly ceded to RGA Group Re and the proper provisions and limits are established on RGA Group Re’s administration system.

Works directly with Ceding Company and / or Broker to resolve questions and issues that arise from these claims.

Identifies claim and underwriting issues that might affect the claims process or administrative services. Interact with underwriting department on contract issues and Ceding Companies and / or Brokers claim appeals.

May escalate issue to Sr. Claim Examiner and / or Department Manager as appropriate.

• Establishes, monitors and updates system with appropriate reserves or reserve assumptions.
• Participates in internal claim audits, marketing visits, client training, and industry meetings.
• Accurately adjudicate and processes payment for approved claims via ACH or wire transfer. Also approves claim reinsurance reimbursements within authority limits.

Participate in the administrative systems user testing.

Potential cross training on all lines of Group Reinsurance business (Disability, Life & Special Risk and Medical / Managed Care).

Requirements

Education and Experience

Required :

• Associate's Degree or equivalent experience in insurance, reinsurance, or financial services
• 2-4 years claims adjudication experience in Medical, Managed care and or stop loss insurance

Preferred :

• 5+ years claims adjudication experience in Medical, Managed Care and / or Stop Loss insurance
• Progress toward ARA, FLMI, ALHC or other relevant professional accreditation
• Reinsurance industry knowledge

Skills and Abilities

Required :

• Basic Microsoft Word Skills
• Intermediate Microsoft Excel Skills
• Intermediate Microsoft Outlook Skills
• Basic Query or Business Objects skills
• Ability to read and interpret insurance documents and reinsurance treaties and apply appropriately.
• Ability to be flexible when needed, take initiative, and demonstrate accountability.
• Intermediate oral and written communication skills demonstrating ability to share and impart knowledge
• Ability to quickly adapt to new methods, work under tight deadlines and stressful conditions.
• Ability to set goals, multitask and prioritize workload.
• Basic level of investigative, analytical and problem-solving skills
• Ability to work well within a team environment and participate in department projects
• Ability to balance detail with departmental goals / objectives
• Ability to foster customer service as needed
• Ability to liaise with individuals across a wide variety of operational, functional, and technical disciplines and work well with all levels of management.
• Ability to travel up to 5% required

Preferred :

• Proficient knowledge of medical terminology and Coding
30+ days ago