Sr Claims Examiner I

📋 Description

• • Review and adjudicate standard and moderately complex life, annuity, and RPS claims in strict compliance with contract provisions, company policies, and regulatory requirements.
• • Process and pay claims up to $1M within established Service Level Agreements (SLAs) while ensuring accuracy and timeliness.
• • Validate beneficiary designations and execute payments according to documented procedures and team SLAs.
• • Apply established procedures and regulatory guidelines to determine if claims submissions are in "good order."
• • Identify, document, and escalate highly complex, unusual, or non-standard claims to senior team members or management for further review.
• • Maintain complete, accurate, and auditable records for all claims handled, ensuring compliance with internal and external documentation standards.
• • Communicate clearly and professionally with beneficiaries, agents, and internal stakeholders to resolve inquiries, provide updates, and foster strong customer relationships.
• • Navigate multiple administrative systems, claims workflows, and imaging tools simultaneously while adhering to standard operating procedures (SOPs).
• • Consistently meet individual and team performance metrics tied to SLAs, accuracy rates, and processing timelines.
• • Participate in ongoing training and development programs to enhance technical knowledge, regulatory understanding, and claims processing expertise.
• • Demonstrate proficiency in digital tools and claims systems, including emerging AI applications such as Microsoft CoPilot.
• • Work core business hours between 8:30 AM and 6:00 PM EST to ensure alignment with team operations and customer service expectations.
• • Maintain a strong customer service mindset with professionalism, empathy, accountability, and ownership in all interactions.
• • Adapt quickly to evolving procedures, regulatory changes, and internal process updates while maintaining high standards of accuracy and efficiency.
• • Collaborate effectively within a team environment to support shared goals, knowledge sharing, and operational continuity.