Company :HM Insurance Group
Job Description :
This job reviews, evaluates, and processes various Excess Risk and Reinsurance Claims. The incumbent responsible for the conversation of positive client relationships, education, and analysis of client claim losses as well as analysis of current issues regarding client activities with dissemination of this information to the management.
- Display effective communication skills while providing counseling to clients and assisting with client service programs and interacting with internal departments
- Claims Analysis: Process daily incoming Stop Loss claims. Monitor, review and analyze various potential claims with emphasis on controlling losses through effective managed care. Frequent overnight travel nationally to assist Manager with performing client performance evaluations to assess the accuracy of client reports submitted to the Organization, efficiency of claim operations, and adequacy of systems and procedures. Evaluate various claims submitted by Third Party Administrators (TPAs) on behalf of self-funded clients for compliance with the following: underlying policy provisions, federal and state regulatory guidelines, and industry standards.
- Client Interaction: Approve claim payments on behalf of multiple clients. Provide client counseling and support services. Assist in the client service programs including revising and establishing procedures, protocols and ensuring client satisfaction with the Organization
- Other duties as assigned or requested.
- High School Diploma/GED
- Bachelor’s Degree
- 5 years of relevant, progressive experience in health insurance claims
- Prior experience processing 1st dollar health insurance claims
- Prior experience with Medical Terminology
- Prior experience in a Stop Loss Claim Analyst role
- Ability to communicate concise accurate information effectively
- Organizational skills
- Ability to manage time effectively
- Ability to work independently
- Problem Solving and analytical skills
Language (Other than English):
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Teaches / trains others regularly
Travel regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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