Accident & Health Senior Claims Examiner

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Job description

This position will be responsible for analyzing and determining eligibility of claims on Managed Care business (HMO Re/Provider Excess/Stop Loss/Excess Loss). Interprets contract/policy/DOFR wording as it relates to claims submissions, ensures all required documentation is received to properly adjudicate claims, issue reimbursement, and resolve appeals. Manages relations with external customers and satisfies inquiries in a timely fashion.

Responsibilities:

• Analyzes and determines eligibility of reinsurance Accident & Health claims; interprets and verifies that the reinsurance claim was properly ceded to Odyssey and the proper provisions and limits are established on Odyssey's administrative and financial systems. 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 Broker claim appeals. May escalate issue to department manager and/or senior claims management as appropriate.

• Establishes, monitors and updates system with appropriate reserves.

• Accurately adjudicate and process payment for approved claims via ACH. Accurately and promptly provide adjudication results with their respective reports to various Ceding Company's and/or Broker's secure portals. Approve claim reinsurance reimbursements within authority limits.

• Identified opportunities for investigation or application of "best practices" in client claim activities. Participates in marketing visits, in-house training, industry meetings and conferences.

• Potential cross-training for all lines of A&H Reinsurance business (HMO Re, Provider Excess, Stop Loss, Specific Excess and others)

Requirements:

• Bachelor's Degree or equivalent experience in insurance, reinsurance or financial services
• 10+ years experience with HMO Re, Provider Excess, Stop Loss and Managed Care claims handling/adjudication.
• Intermediate to Advanced Microsoft Excel Skills.
• Ability to read and interpret insurance documents/policies and reinsurance treaties and apply appropriately.
• Ability to be flexible when needed, take initiative, and demonstrate accountability.
• Advanced oral and written communication skills demonstrating ability to share and impart knowledge.
• Self-starter with ability to set goals, multitask and prioritize workload.
• Intermediate level of investigative, analytical, and problem-solving skills.
• Respond to customer and broker requests in a timely manner, responding promptly and keeping them informed of delays before they ask.
• Take appropriate steps to resolve problems to the customer's or broker's satisfaction.
• Broad understanding of the insurance industry and related organizational principals and practice.
• Communicate in a clear and concise manner, while also demonstrating receptivity through active listening.
• Ability to concentrate, meet deadlines, work on several projects at the same period, and adapt to interruptions.
• Ability to provide organ transplant network comparisons to clients/brokers using a contract comparison tool.
• Ability to quickly adapt to new methods, work under tight deadlines and conditions.
• 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 work well independently as well as within a team environment.
• Participate in marketing visits, client training, industry meetings and conferences.
• Ability to travel up to 5%.

Preferred Skills:

• Reinsurance industry knowledge
• Experience performing claim audits
• Proficient knowledge of medical terminology
• Working knowledge of:

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