Hm Life Insurance Company
Job Description :
I. GENERAL OVERVIEW:
Acting in the role of Excess Risk Claim Unit Assistant, this position is responsible for Evaluating specific Stop Loss notice and/or claim information for potentially catastrophic and/or existing catastrophic claims, identifying potential enhancements to applications and/or processes to improve efficiency, communicating effectively with clinical staff, claim staff and department management and promoting a culture of performance excellence departmentally.
II. ESSENTIAL RESPONSIBILITIES:
1. Evaluating Specific Stop Loss notice and/or claim information for potentially catastrophic and/or existing catastrophic claims.
• Evaluate each notice and/or claim and execute the appropriate business rules for triaging notice of potential claim data to clinicians and/or actual claim data to the claim analysts.
• Create the appropriate system entries (notice or claim payment request) based on the information evaluated.
2. Identifying potential enhancements to applications and/or processes to improve efficiency
• Make recommendations to management, as appropriate, for application changes to improve efficiency.
• Communicate with management regarding process improvement opportunities to improve efficiency.
3. Communicating effectively with clinical staff, claim staff and department management.
• Identify and articulate problems/issues to various staff members, including all levels of department management.
• Participate in functional walk-throughs as requested and provide feedback.
4. Promoting a culture of performance excellence departmentally
• Enhancing job skills through training and participation in workshops
• Participating in process and operational improvement opportunities
• Building and maintaining effective relationships throughout the department to build performance excellence.
5. Other duties as assigned or requested.
• High School Diploma/GED
• Minimum 3 years’ experience in claim administration activities
• Working knowledge of ICD, HCPC, CPT4 coding and medical terminology
• Prior experience with specific stop loss claims and/or notices of potential claims
• Strong medical policy background
• Prior experience with researching medical claim data
IV. SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees?
V. WORK ENVIRONMENT
Is Travel Required?
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