Examiner Excess Loss
- Norcross, GA
What you'll be doing
- Audit individual excess loss claim submission through analysis of excess loss policy provisions, employer plan document provisions, administrative agreements, and cost containment vendor agreements to process accurate claim reimbursements made payable to the policyholder. Review potential claim notices and claim submissions for cost containment opportunities and refer to medical risk consultants or cost containment specialist. Audit and make reimbursement determinations of excess loss claims in accordance with the provisions of the policyholder's plan document and excess loss policy. Adjudicate claim reimbursements within stated turnaround time goals. Maintain> 99% quality on claim procedures and financial accuracy which includes required documentation of pertinent claimant, plan and policy information. Maintain current pending claims with consistent follow up, documentation, and resolution or closure within defined timeframes. Interact with TPA contacts and other resources to clearly communicate information needed to make reimbursement decision. Provide prompt turnaround when requested information is received for reimbursement or denial. Review advance notices of potential claims to identify and refer cases expected to become excess loss claims, requiring MRC attention for renewal information or cost containment. Alert MRC's, RGMs, and underwriters of potential catastrophic claims risk as well as unusual and complex claim issues. Interact with internal and external customers responding to inquiries, handle appeals, facilitating claim resolutions, and providing and obtaining education in industry claim treads and cost containment solutions. Perform special projects as identified by management.
What your background should be
- Minimum 1-3 years of first dollar medical claims paying experience required. Specific industry and/or specialty experience required. Must know the fundamental concepts of group health insurance, ERISA, employee benefit plans and reinsurance. Proficient in medical terminology, use of icd-9 and CPT coding, ub92 identifiers and HCFA forms. Strong analytical and contract interpretation skills. Strong communication skills (oral and written). Objective decision making skill. Ability to work with deadlines.
Required Schooling / Training
- High school diploma required.
Who is the client company
- This is a United States-based family of companies providing retirement plans, employee benefits, annuities and life insurance through independent distributors nationwide.
- If you are interested in this position, send your resume to firstname.lastname@example.org