Job Summary: 

• Relying on instructions and pre-established guidelines
• Responsible for accomplishing the following as guided by others.
• Review coverage claims, and determine whether the matter is covered under the applicable policy.
• Take responsibility for investigating coverage issues.
• Draft action plans, including coverage recommendations, for the approval of Claims Managers.
• Establish and revise claim reserves based on claim developments and counsel liability assessments.
• Draft coverage determination letters, including reservation of rights and denial letters.
• Obtain updates from defense counsel and/or coverage counsel and/or the Insured, as appropriate.
• Authorize settlements based on liability and other considerations after receiving approval from claims management.
• Review, approve, and reimburse the Insured for legal, expert/vendor invoices, and settlement.
• Conduct detailed bill reviews to ensure appropriate payment.
• Maintain a claim file by accurately documenting all communications and activities.
• Communicate with brokers or reinsured clients to obtain information necessary for processing claims.

Skills on Resume:

• Claims Review (Hard Skills)
• Claims Investigation (Hard Skills)
• Action Planning (Hard Skills)
• Reserving & Liability (Hard Skills)
• Legal Letter Drafting (Hard Skills)
• Settlement Approval (Hard Skills)
• Bill Review (Hard Skills)
• Communication (Soft Skills) 

Job Summary: 

• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions
• Process claims timely and accurately in full accordance with Medicare-Medicaid and health Plan guidelines
• Alert management promptly of any identified issues that impact quality and production
• Process claims following current and relevant provisions of applicable plan documents
• Prepare correspondence reports clearly and concisely for business files
• Monitor and follow up on pending claims activity immediately to ensure accuracy
• Exceed minimum production averages with accurate payment and procedure reports
• Provide phone backup for the Customer Service department
• Assist manager with ad-hoc reports and projects when requested

Skills on Resume:

• Claims Processing (Hard Skills)
• Issue Identification (Soft Skills)
• Report Preparation (Hard Skills)
• Claims Monitoring (Hard Skills)
• Production Efficiency (Hard Skills)
• Customer Service Support (Soft Skills)
• Ad-hoc Reporting (Hard Skills)
• Communication (Soft Skills) 

Job Summary: 

• Investigate, evaluate, and settle or manage the defense of claims, including selection and oversight of independent adjusters and counsel and control of loss adjustment expenses, within established authority.
• Identify, evaluate, and determine, in consultation with Company counsel, respective rights and obligations of the Company, Insured, and third parties under all applicable insurance policies.
• Establish and modify loss and expense reserves as information regarding the claim develops.
• Prepare accurate and timely case summaries, evaluations, and reports
• Prepare, maintain, and periodically review appropriate Claim Files and journals and all required electronic and other records, and provide information regarding claims
• Maintain current knowledge of insurance and claim management principles and practices through review of published opinions, trade periodicals, and other professional literature and presentations.
• Travel to represent the Company in settlement conferences and other proceedings.
• Ensures adjudication of assigned medical claims in an accurate and timely manner to include the completion of adjustments, recovery of funds, member service incident reports, and the coordination of benefits.
• Verifies adjudicate claim payments independently and following plan guidelines.
• Provides timely and accurate information to plan members and providers regarding claims, benefits, member out-of-pocket expenses, and payments via telephone or in writing.

Skills on Resume:

• Claims Investigation (Hard Skills)
• Legal Consultation (Hard Skills)
• Loss Reserve Management (Hard Skills)
• Report Preparation (Hard Skills)
• Claim File Management (Hard Skills)
• Insurance Knowledge (Hard Skills)
• Settlement Representation (Soft Skills)
• Claims Adjudication (Hard Skills) 

Job Summary: 

• Respond to a high volume of calls and inquiries via telephone, email, and system tickets in a timely fashion by listening and showing empathy
• Assign claims, investigate coverage - liability - damages, and settle claims within prescribed authority levels.
• Recognize any potential claims issues and distinguish between minor and major claims issues
• Notify Claims Management for appropriate assignment and authority
• Communicate with policyholders, witnesses, and claimants to gather information, refer tasks to auxiliary resources, and advise as to the proper course of action
• Appropriately document and record events as they occur
• Recognize what exposures need to be opened based on the facts of the loss and coverage of the policy
• Comply with all statutory and regulatory requirements in multiple jurisdictions
• Meet quality assurance standards and performance goals
• Complete training, along with the ability to obtain a Texas Adjuster License

Skills on Resume:

• Call & Inquiry Management (Soft Skills)
• Claims Investigation & Settlement (Hard Skills)
• Issue Identification (Soft Skills)
• Claims Documentation (Hard Skills)
• Exposure Recognition (Hard Skills)
• Regulatory Compliance (Hard Skills)
• Quality Assurance (Hard Skills)
• Licensing & Training (Hard Skills) 

Job Summary: 

• Review and accurately input all information on IMRF forms 5.40, 5.41, 5.42, and supporting documentation submitted by IMRF members.
• Contact other IMRF departments to obtain information and request corrections in an effort to resolve most internal conditions preventing payment of benefits.
• Contact employers, employees, physicians, hospitals, Social Security, and worker’s compensation carriers to obtain information necessary to determine eligibility, duration, and amount of most disability benefits.
• Review medical records to determine the extent of disability for temporary/total and permanent claims, and to make recommendations concerning the application of pre-existing condition language.  
• Approve members for temporary disability benefits and make recommendations concerning member’s eligibility for Total and Permanent disability.
• Provide customer service to employers, employees, medical providers, and other IMRF departments by answering questions concerning procedures and benefits, either in writing or by telephone. 
• Maintain a work in progress that meets the service goals established by the Disability Manager.
• Provide detailed information to vested members concerning retirement benefits, including a comparison between IMRF benefits available to disabled members and benefits available to retired members.
• Analyze the initial claim application and supporting documents to determine what additional requests for information must be made to obtain the necessary level of documentation to approve or deny the application for disability benefits.
• Establish follow-up dates and methods for each ongoing claim assigned to them.
• Write letters to the IMRF medical consultants that summarize the medical and non-medical facts of disability cases. 

Skills on Resume:

• IMRF Form Processing (Hard Skills)
• Information Gathering (Hard Skills)
• Medical Record Review (Hard Skills)
• Disability Benefits Analysis (Hard Skills)
• Customer Service (Soft Skills)
• Work Progress Management (Hard Skills)
• Retirement Benefits Analysis (Hard Skills)
• Letter Writing (Hard Skills) 

Job Summary: 

• Examine and process medical, dental, and vision claims including physician claims, Medicaid reclamation, HIPD, FSA, other re-pricing claims, emergency room, outpatient lab and x-ray, accident and Third Party Liability (TPL) claims, Medicare Secondary Payer (MSP) and surgery claims.
• Resolve pended claims within Employee Retirement Income Security Act (ERISA) guidelines
• Research and complete all correspondence related to all electronic and paper claims assigned
• Meet department standards for both production and quality
• Maintain a Health Insurance Portability and Accountability Act (HIPAA) compliant workstation.
• Utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client and enrollee data.
• Respond to internal/external customer inquiries and requests within the established timeframe
• Utilize all capabilities to satisfy one mission to enhance the competitiveness and profitability of members.
• Help members succeed by being curious and striving to understand what others are trying to achieve, planning and executing work helpfully and collaboratively
• Adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating positive impact, and being diligent in delivering results.

Skills on Resume:

• Claims Processing (Hard Skills)
• ERISA Compliance (Hard Skills)
• Correspondence Management (Hard Skills)
• Production & Quality Standards (Hard Skills)
• HIPAA Compliance (Hard Skills)
• Customer Inquiry Response (Soft Skills)
• Collaboration (Soft Skills)
• Accountability & Results Delivery (Soft Skills)