索赔审查员
Claims Examiner
职位名称：理赔审查员 – 人寿、意外、重大疾病、长期护理和住院补偿
简介：作为专注于意外、重大疾病、短期伤残和住院补偿业务线的理赔分析师，您将负责准确评估和处理与这些保险产品的相关理赔。您的职责包括调查理赔案件、核实保单保障范围、确定责任，并确保符合监管要求。此职位需要具备强大的分析能力、细致的关注力和同理心，因为您将与理赔申请人、医疗提供者和其他利益相关者互动，以促进及时公正的理赔解决。
主要职责：
理赔处理与评估：
- 评估收到的理赔，确定资格、保障范围和有效性。
- 进行全面调查，包括查阅医疗记录和其他相关文件。
- 分析保单条款和合同协议，评估理赔的有效性。
- 使用理赔管理系统记录发现并高效处理理赔。
沟通与客户服务：
- 与保单持有人、受益人和医疗提供者有效沟通理赔状态和要求。
- 及时回应查询，并在整个理赔过程中保持专业且富有同理心的沟通。
- 处理客户关切，并在需要时将复杂问题上报给高级理赔人员或管理层。
合规与文档：
- 确保符合公司政策、流程和监管要求。
- 保持与理赔活动相关的准确记录和文档。
- 遵循既定的理赔裁定和付款授权指南。
质量保证与改进：
- 识别理赔部门内流程改进和效率提升的机会。
- 参与质量保证计划，维护服务标准并改进理赔处理实践。
- 与团队成员和管理层合作，实施最佳实践并提升整体部门绩效。
报告与分析：
- 生成报告并提供理赔趋势、处理时间和结果的数据分析。
- 为理赔运营的管理报告和演示文稿的开发做出贡献。
- 资格要求：
- 本科及以上学历，主修工商管理、保险、医疗管理或相关专业
查看英文原文
Job Title: Claims Examiner – Life, Accident, Critical Illness, LTC, and Hospital Indemnity
Overview: As a Claims Analyst specializing in Accident, Critical Illness, Short-Term Disability, and Hospital Indemnity lines of business, you will be responsible for accurately assessing and processing claims related to these insurance products. Your role will involve investigating claims, verifying policy coverage, determining liability, and ensuring compliance with regulatory requirements. Strong analytical skills, attention to detail, and empathy are essential for this position as you will interact with claimants, healthcare providers, and other stakeholders to facilitate timely and fair claim settlements.
Key Responsibilities:
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.
Qualifications:
- Bachelor's degree in business administration, insurance, healthcare management, or a related field (or equivalent work experience).
- Prior experience in claims processing, preferably in Accident, Critical Illness, LTC, and/or Hospital Indemnity insurance.
- Knowledge of insurance principles, policies, and practices related to accident, critical illness, LTC, and hospital indemnity lines of business.
- Strong analytical and problem-solving skills with the ability to interpret complex documents and policies.
- Excellent communication skills, both verbal and written, with a customer-focused approach.
- Proficiency in using claims management software and Microsoft Office Suite (Excel, Word, Outlook).
Preferred Skills:
- ACS and/or ALHC Designation
- Experience with medical terminology and healthcare billing practices.
- Understanding of regulatory requirements governing claims processing in the insurance industry.
Attributes:
- Demonstrated strong punctuality and attendance practices.
- Detail-oriented with a commitment to accuracy and thoroughness.
- Ability to work effectively in a team environment and independently when necessary.
- Strong organizational skills with the ability to prioritize and manage multiple tasks.
- Adaptable to changing priorities and comfortable working in a fast-paced environment.
Work Environment:
- Remote work environment role with regular business hours (9:00am – 6:00pm Eastern).
- Occasional overtime or weekend work may be required during peak periods or to meet deadlines.
- Opportunities for professional development and career advancement within the claims department or broader insurance organization.
The candidate must possess a curiosity and willingness to actively adopt and leverage emerging AI tools to improve workflows, solve problems, and drive efficiency along with being comfortable using a range of AI-enabled tools (such as copilots, chat-based AI, and automation solutions) as part of everyday work
Hourly Rate - $21.00
Originally posted on Himalayas