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Claims Examiner II A&H
2 months ago
About the Role
The Claims Examiner II A&H is responsible for executing a specific opinion, investigating, evaluating, negotiating, and resolving claims assigned for accident coverage. This includes reimbursement of medical expenses due to national and foreign accidents, bodily injuries that could cause accidental death, compensation for diagnosis of serious illnesses, and compensation for funeral expenses.
Key Responsibilities
- Investigate and evaluate claims to determine coverage and liability
- Negotiate and resolve claims with claimants and medical providers
- Manage queries on the handling of key complaints, coverage determination, quantum analysis, and legal liability assessment
- Ensure effective supplier and litigation management of complex claims
- Report key complaint messages to team managers and internal stakeholders
- Communicate with internal and external stakeholders, including technical claims experts, medical providers, and thought leaders
- Deliver technical training to colleagues and external contacts
- Assist in continuous improvement across the region through supporting Regional Quality Assurance/Audit processes
- Ensure compliance with best practice procedures for complex claims, consistent with global best practices
- Handle higher-level complexity claims, Complex losses within the limits of authority
- Maintain the record of timely reservations
- Contribute to the containment of the cost of the business line based on the usual expense in each recovery
- Keep updating each claim within periods no longer than 90 days
Requirements
- Experience in insurance sector, specifically in the management of personal accident claims, traveler policies, or knowledge in the designation of beneficiaries in legal status
- Knowledge of sentencing processes in claims for bodily injuries, deaths, and diagnoses of serious illnesses
- Basic knowledge of medical language (injury diagnoses)
- Basic knowledge of the General Conditions of Personal Accidents
- Experience in administration and file management
- Basic knowledge of accounts payable management
Preferred Qualifications
- Formal education: Graduate in Administration, but with experience in health areas
- Experience: 0-3 years of claims handling or case management for medical or personal accident claims portfolio
- 0-2 years of handling and managing medical service providers networks, cost containment strategies, and continuous improvement strategies
- Basic policy wording interpretation and claims resolution on personal accident or medical expenses policies
- Basic to medium experience in the handling of complex case management (e.g. cancer, etc.)
Soft Skills
- Ability to prioritize and multitask effectively in a fast-paced environment
- Competency in desk management, telephone etiquette, time management, and dealing with difficult customers
- Experience in effectively following up on technical claims audit recommendations and continuous improvement in claims management
- Commitment to the operation to achieve the objectives
- Effective communication with clients and openness to teamwork
