Claims Examiner II Supplemental Health

Job Responsibilities and Requirements

The Supplemental Health Claims Examiner II evaluates and processes lines coverage handled in the Supplemental Health Claims Department in accordance with applicable law and company guidelines. Claims may include Wellness, Accident, Critical Illness, and Hospital Indemnity benefits.  The goal of the role is to consistently pay the accurate amount for each claim in accordance with the contract. This role also provides customer service that is respectful, prompt, concise, and accurate in an environment with competing demands.

Analysis and Adjudication

• Reviews and processes Wellness, Accident, Critical Illness, or Hospital Indemnity claim documents and proofs to verify eligibility based on contractual provisions and premium status within company guidelines and applicable law. Authorizes claim payments up to $10,000.
• Determines proper payee, verifies the accuracy of benefit amount calculations, and processes benefit payments up to $10,000.
• Processes system tasks and pending claims in accordance with department guidelines.
• Provides payment or denials promptly and in full compliance with department procedures and regulations.
• Participates in special projects and process improvements.

Research

• Develop an understanding and working knowledge of products, policies, and contracts.
• Develop an understanding of the applicable contract/policy definitions of disability and relevant provisions, clauses, exclusions, as well as statutory requirements.
• Review medical and applicable information to verify eligibility.
• Determines proper payee, and verifies the accuracy of benefit amount calculations, and premium amount calculations under contributory plans.
• Fully investigates all relevant claim issues.

Case Management

• Provides clear, concise, and accurate information to claimants as well as within the claims administrative system.
• Creates necessary correspondence for benefit denials, partial denials, or eligibility denials. 
• Manages assigned caseload as outlined in Key Measures.
• Requests any necessary additional information from the policyholder medical providers, or vendors when needed.
• Utilizes the most efficient means to obtain claim information.

Customer Service

• Provides customer service that is respectful, prompt, concise, and accurate in an environment with competing demands.
• Establishes, communicates, and manages claimant and policyholder expectations.
• Documents claim file actions and telephone conversations appropriately.

 Required Knowledge, Skills, Abilities and/or Related Experience

• High School Diploma or equivalent required. Relevant Associates or Bachelor’s Degree highly preferred.
• HIAA, LOMA or ICA courses desirable
• Minimum of two (2) years related claims experience required.
• Work experience in decision-making and information analysis.
• Requires excellent communication skills.
• Demonstrated prioritization and organization skills.
• Experience working in confidential/protected identification environments.
• Good math and calculation skills.
• Proficient in Microsoft Office products.
• Prior experience using an automated claim system required.

Ability to Travel:None

PHYSICAL REQUIREMENTS

When used in the description below, the following terms are defined as:

“Occasional”: done only from time to time, but necessary when it is performed

“Frequent”: regularly performed; generally an act that is required on a daily basis

“Continuous”: typically performed for the majority of an employee’s shift

Sitting for prolonged periods of time, frequently standing, walking distances up to one mile, bending, crouching, kneeling, reaching, occasionally lifting 25lbs, extensive typing, picking up and holding small objecting and otherwise using primarily the fingers rather than the entire hand.  Employee is required to have visual acuity sufficient to perform activities such as preparing and analyzing data and figures; transcribing notes; viewing a computer terminal and extensive reading. Employee is required to have hearing sufficient to understand verbal instruction and answer telephones.  Reliance Matrix will provide qualified employees with a reasonable accommodation in accordance with applicable law.

CORE VALUES

• Collaboration
• Compassion
• Empowerment
• Integrity
• Fun

The above description reflects the general details considered necessary to describe the principle responsibilities and functions of the job identified and shall not be construed as a detailed description of all the work requirements that may be inherent to this job.

Work location may be flexible if approved by the Company.

What We Offer

At Reliance Matrix, we believe that fostering an inclusive culture allows us to realize more of our potential. And we can’t do this without our most important asset—you.

That is why we offer a competitive pay package and a range of benefits to help team members thrive in their financial, physical, and mental wellbeing.  

Our Benefits:

• An annual performance bonus for all team members
• Generous 401(k) company match that is immediately vested
• A choice of three medical plans (that include prescription drug coverage) to suit your unique needs.  For High Deductible Health Plan enrollees, a company contribution to your Health Savings Account
• Multiple options for dental and vision coverage
• Company provided Life & Disability Insurance to ensure financial protection when you need it most
• Family friendly benefits including Paid Parental Leave & Adoption Assistance 
• Hybrid work arrangements for eligible roles
• Tuition Reimbursement and Continuing Professional Education
• Paid Time Off – new hires start with at least 20 days of PTO per year in addition to nine company paid holidays.  As you grow with us, your PTO may increase based on your level within the company and years of service. 
• Volunteer days, community partnerships, and Employee Assistance Program
• Ability to connect with colleagues around the country through our Employee Resource Group program

Our Values:

• Sustainable Performance
• Continuous Improvement
• Customer Experience
• Collaboration
• Empowerment
• Sense of Community

EEO Statement

Reliance Matrix is an equal opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, national origin, citizenship, age or disability, or any other classification or characteristic protected by federal or state law or regulation. We assure you that your opportunity for employment depends solely on your qualifications.