Claims Examiner

Key Responsibilities:Link and set up Substantive, Group, Wellness, and Physician Consult claims in the work distribution and policy administration system. Evaluate submitted claims by reviewing policy provisions and applicable laws to accurately adjudicate claims. Assist claimants by providing necessary forms, instructions, and support to ensure a smooth claims process. Draft and send letters requesting relevant medical or other information for claim analysis. Ensure timely requests, follow-ups, and closeouts on all submitted claims. Maintain claim files in compliance with Fair Claims Settlement Practice Regulations and company standards. Communicate with policyholders, beneficiaries, and healthcare providers regarding claim handling, denials, payments, and policy provisions in a courteous and professional manner. Process payments, denials, or requests for additional information for Wellness, Physician Consult benefits, group, and substantive products. Utilize existing knowledge of medical terminology, diseases, conditions, and treatments relevant to company product lines. Maintain satisfactory monthly performance rates for processing multiple substantive and group products. Perform additional duties as assigned. Qualifications:Minimum of 2 years of experience in life/health claims or a related field. High School Diploma or GED required; Bachelor’s degree preferred. Completion of LOMA or AHIP coursework or willingness to enroll. Proficiency in Microsoft Outlook, Word, and Excel; typing speed of 40+ WPM. Strong written and verbal communication, organizational, and analytical skills.