Claims Examiner

About This Role

This role involves evaluating and processing claims to determine if they are payable, deferred, or declined. The Claims Examiner ensures claims are handled according to policy provisions, regulatory requirements, and company guidelines, while providing timely and professional correspondence to customers.

Responsibilities

• Evaluate claims against eligibility requirements, provisions, and applicable processes
• Enter and maintain accurate data in claims processing systems, including written correspondence
• Research and gather additional information to support claim decisions
• Perform benefit calculations and conduct claim investigations
• Communicate with internal and external customers via phone and written correspondence
• Maintain positive customer relationships through professional and empathetic interactions
• Participate in departmental meetings, training activities, and continuous improvement initiatives
• Support occasional special projects and other duties as assigned

Requirements

• High School diploma or equivalent required
• Minimum 2+ years of general work experience
• Strong analytical and problem-solving skills with attention to detail
• Ability to evaluate claims against eligibility requirements and interpret policy language
• Effective verbal and written communication skills
• Basic math skills and proficiency in a PC environment, including Microsoft Office
• Ability to build and maintain positive customer relationships