Benefits Adjuster II
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Position Overview
We are seeking a detail-oriented and analytical Benefits Adjuster II to evaluate, process, audit, and adjust moderately complex insurance claims for various insurance products, including Accident, Critical Illness, Hospital Indemnity, Health Reimbursement Arrangements (HRA), Short-Term Disability, and Medlink claims.
The Benefits Adjuster II will be responsible for reviewing claim documentation, interpreting insurance policies, determining benefit eligibility, and ensuring claims are processed accurately and in accordance with company policies, applicable insurance laws, regulatory requirements, and established guidelines.
This position also involves communicating with claimants, medical providers, employers, and other internal and external stakeholders to provide guidance, resolve inquiries, and deliver excellent customer service.
Key Duties and Responsibilities
Claims Processing and Evaluation
Process, review, audit, and adjust moderately complex insurance claims in accordance with company policies, insurance regulations, and established adjusting guidelines.
Evaluate claim documentation and verify information with relevant parties to determine benefit eligibility and ensure accurate claim decisions.
Interpret insurance policies, contracts, coverage provisions, and benefit limitations to determine appropriate claim outcomes.
Identify claims requiring additional investigation and coordinate with internal or external consultants when necessary.
Handle billing and collection of deposits for reimbursement related to Health Reimbursement Arrangements (HRA), as applicable.
Customer Service and Claim Resolution
Respond to customer inquiries and provide accurate information regarding insurance coverage, claim status, and benefit eligibility.
Communicate professionally with claimants and other stakeholders through verbal and written correspondence.
Follow up on customer concerns to ensure timely and appropriate resolution.
Establish clear expectations regarding claim requirements, processing, and benefit determinations.
Communication and Coordination
Communicate claim decisions and requirements to insured individuals, medical providers, employers, third-party administrators (TPAs), brokers, and consultants.
Follow up on pending claims and outstanding documentation to facilitate timely processing.
Document customer complaints, actions taken, and resolutions in accordance with departmental procedures.
Team Support and Training
Provide guidance, training, and support to less experienced team members.
Share knowledge and best practices to improve claim processing accuracy, customer service, and overall team performance.
Assist colleagues in resolving complex customer concerns when needed.
Cross-Training and Additional Responsibilities
Cross-train and process claims outside the primary area of responsibility as requested by management.
Adapt to changing departmental priorities and perform additional duties as assigned.
Requirements and Qualifications
Education:
Associate degree required.
Equivalent business experience may be considered in lieu of formal education.
Professional Experience:
Minimum of 3 years of job-specific experience in insurance claims processing, benefits administration, or a related field.
Previous experience evaluating, processing, auditing, or adjusting insurance claims.
Knowledge of insurance claims procedures, policy interpretation, and applicable regulations is preferred.
Technical Skills:
Good understanding of medical terminology and human physiology.
Intermediate proficiency in Microsoft Office applications, particularly Excel and Word.
Proficiency with Windows-based computer systems and the ability to learn new software applications.
Experience working with case management systems and electronic documentation.
Ability to work effectively in a paperless environment.
Core Competencies:
Strong analytical and problem-solving skills.
Excellent verbal and written communication skills.
Strong attention to detail and accuracy.
Good organizational and time-management skills.
Ability to interpret insurance contracts and apply benefit provisions appropriately.
Sound judgment and decision-making abilities.
Ability to manage multiple priorities in a fast-paced environment.
Strong interpersonal skills and a collaborative approach to teamwork.
Professional attitude and commitment to delivering excellent customer service.
Flexibility to work overtime when necessary.
What Success Looks Like in This Role
Consistently meets or exceeds productivity and workload management expectations.
Maintains high levels of accuracy and quality in claim processing.
Makes fair and accurate decisions on moderately complex claims with limited supervision.
Demonstrates a thorough understanding of departmental procedures, insurance contracts, and benefit provisions.
Effectively communicates claim requirements and decisions to customers.
Consistently delivers excellent customer service and meets established quality standards.
No Third Party Agencies or Submissions Will Be Accepted.
Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP
Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.