Complex Claims Specialist – Allied Healthcare Providers

JOB DESCRIPTION

Essential Duties & Responsibilities :

Performs a combination of duties in accordance with departmental guidelines :

• Manages an inventory of moderate to high complexity and exposure Healthcare claims by following company protocols to verify policy coverage, conduct investigations, develop and employ resolution strategies, and authorize disbursements within authority limits.
• Provides exceptional customer service by interacting professionally and effectively with insureds, claimants and business partners, achieving quality and cycle time standards, providing regular, timely updates and responding promptly to inquiries and requests for information.
• Verifies coverage and establishes timely and adequate reserves by reviewing and interpreting policy language and partnering with coverage counsel on more complex matters , estimating potential claim valuation, and following company's claim handling protocols.
• Establishes and maintains working relationships with appropriate internal and external work partners, suppliers and experts by identifying and collaborating with resources that are needed to effectively resolve claims.
• Authorizes and ensures claim disbursements within authority limit by determining liability and compensability of the claim, negotiating settlements and escalating to manager as appropriate.
• Contributes to expense management by timely and accurately resolving claims, selecting and actively overseeing appropriate resources, and delivering high quality service.
• Identifies and addresses subrogation / salvage opportunities or potential fraud occurrences by evaluating the facts of the claim and making referrals to appropriate Recovery or SIU resources for further investigation.
• Achieves quality standards on every file by following all company guidelines, achieving quality and cycle time targets, ensuring proper documentation and issuing appropriate claim disbursements.
• Maintains compliance with state / local regulatory requirements by following company guidelines, and staying current on commercial insurance laws, regulations or trends for line of business.
• May serve as a mentor / coach to less experienced claim professionals

May perform additional duties as assigned.

Reporting Relationship

Typically Manager or above

Skills, Knowledge & Abilities

• Solid working knowledge of the Healthcare insurance industry, products, policy language, coverage, and claim practices.
• Solid verbal and written communication skills with the ability to develop positive working relationships, summarize and present information to customers, claimants and senior management as needed.
• Demonstrated ability to develop collaborative business relationships with internal and external work partners.
• Ability to exercise independent judgement, solve moderately complex problems and make sound business decisions.
• Demonstrated investigative experience with an analytical mindset and critical thinking skills.
• Strong work ethic, with demonstrated time management and organizational skills.
• Demonstrated ability to manage multiple priorities in a fast-paced, collaborative environment at high levels of productivity.
• Developing ability to negotiate low to moderately complex settlements.
• Adaptable to a changing environment.
• Knowledge of Microsoft Office Suite and ability to learn business-related software
• Demonstrated ability to value diverse opinions and ideas

Education & Experience

• Bachelor's Degree or equivalent experience. Professional designations preferred. J.D. or medical background a plus.
• Typically a minimum four years of relevant experience, preferably in claim handling or equivalent legal experience.
• Candidates who have successfully completed the CNA Claim Training Program may be considered after 2 years of claim handling experience.
• Must have or be able to obtain and maintain an Insurance Adjuster License within 90 days of hire, where applicable.
• Professional designations are a plus (e.g. CPCU)
30+ days ago