Reliance Matrix
Claims Examiner II - Absence Management Specialist
Reliance Matrix, South Portland, Maine, us, 04106
Claims Examiner II - Absence Management Specialist
The Claims Examiner will act as a liaison between client, employee and healthcare provider. In this position, you are responsible for applying appropriate claims management by providing reliable and responsive service to claimants and clients.
Job Responsibilities
Investigates claim issues providing resolution within departmental and regulatory guidelines.
Interprets and administers contract provisions: eligibility and duration
Accurately codes all system fields with correct financial, diagnosis and duration information.
Coordinates with other departments to ensure appropriate claims transition or facilitate timely return to work.
Adheres to compliance, departmental procedures, and Unfair Claims Practice regulations.
Makes determinations to approve, deny or delay and or reach out to additional resources for review, based on medical certification review and management.
Determines the duration associated with the leave and or disability based on the information given by the healthcare provider.
Process medium to high complexity or technically difficult claims.
Develops and manages claims thought well developed action plans; continues to work the action plan to bring the claim to an appropriate and timely resolution.
Actively contributes to customer service, quality and performance objectives.
Proactively engages in departmental training to remain current with all claim management practices.
Responsible for managing Performance Guarantee clients and meet targeted metrics.
Responsible and accountable for maintaining and protecting personal health information. Must maintain a high level of confidentiality and abide by HIPPA rules and regulations.
Qualifications
High School Diploma or GED (Bachelor’s preferred)
Ability to develop proficiency regarding required RSL products, systems and processes related to the effective delivery of new business proposals
Microsoft Office experience
Attention to detail, analytical skills, and the ability to collaborate with others and work independently
Strong organizational skills, including the ability to prioritize work and multi-task
Customer service experience and orientation
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Job Responsibilities
Investigates claim issues providing resolution within departmental and regulatory guidelines.
Interprets and administers contract provisions: eligibility and duration
Accurately codes all system fields with correct financial, diagnosis and duration information.
Coordinates with other departments to ensure appropriate claims transition or facilitate timely return to work.
Adheres to compliance, departmental procedures, and Unfair Claims Practice regulations.
Makes determinations to approve, deny or delay and or reach out to additional resources for review, based on medical certification review and management.
Determines the duration associated with the leave and or disability based on the information given by the healthcare provider.
Process medium to high complexity or technically difficult claims.
Develops and manages claims thought well developed action plans; continues to work the action plan to bring the claim to an appropriate and timely resolution.
Actively contributes to customer service, quality and performance objectives.
Proactively engages in departmental training to remain current with all claim management practices.
Responsible for managing Performance Guarantee clients and meet targeted metrics.
Responsible and accountable for maintaining and protecting personal health information. Must maintain a high level of confidentiality and abide by HIPPA rules and regulations.
Qualifications
High School Diploma or GED (Bachelor’s preferred)
Ability to develop proficiency regarding required RSL products, systems and processes related to the effective delivery of new business proposals
Microsoft Office experience
Attention to detail, analytical skills, and the ability to collaborate with others and work independently
Strong organizational skills, including the ability to prioritize work and multi-task
Customer service experience and orientation
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