Claim Analyst II (multiple positions)
Job no: 494341
Work type: Full Time Regular
Categories: Customer Service
Ensures the accurate, prompt and thorough evaluation of claims by analyzing and determining the appropriate action steps needed while adhering to both internal and external regulations and ensuring an industry leading customer experience.
Requires independent decision making on complex claims situations using critical thinking. Claims analysis includes: eligibility determination for benefits based on medical information received, contract analysis, customer service, fraud detection and awareness, financial calculations, interpreting information and adhering to all statutory / governmental regulations. This includes analyzing information received, and determining if additional information is required to make an accurate benefits decision.
Embraces the customer-focused strategy and demonstrates our shared values (Customer Focus, Integrity, Innovation, Accountability, and Collaboration) by providing effective customer service resulting in first request resolution and a positive customer experience.
Interacts, responds and resolves customer claim requests via multiple channels including phone, email and written correspondence. Performs multiple work roles with expanded knowledge and skill sets such as data entry, processing multifaceted transactions and handling customer requests under minimal supervision.
Essential Job Functions:
- Building Customer Loyalty - Meeting and exceeding internal or external customer expectations while cultivating relationships that secure commitment and trust.
- Communication - Conveying information and ideas clearly and concisely to individuals or groups in an engaging manner that helps them understand and retain the message; listening actively to others.
- Work Standards - Setting high standards of performance for self and others; assuming responsibility and accountability for successfully completing assignments or tasks; self-imposing standards of excellence rather than having standards imposed.
- Decision Making - Identifying and understanding problems and opportunities by gathering, analyzing, and interpreting quantitative and qualitative information; choosing the best course of action by establishing clear decision criteria, generating and evaluating alternatives, and making timely decisions; taking action that is consistent with available facts and constraints and optimizes probable consequences.
- Initiating Action - Taking prompt action to accomplish work goals; taking action to achieve results beyond what is required; being proactive.
- Adaptability - Maintaining effectiveness when experiencing major changes in work responsibilities or environment (e.g., people, processes, structure, or culture); adjusting effectively to change by exploring the benefits, trying new approaches, and collaborating with others to make the change successful.
- Earning Trust - Gaining others' confidence by acting with integrity and following through on commitments while disclosing own positions; treating others and their ideas with respect and supporting them in the face of challenges.
- Collaborating - Working cooperatively with others to help a team or work group achieve its goals.
- Applied Learning - Assimilating and applying new job-related information in a timely manner.
- Accurately determines complex claim benefits payable based on medical records, contract language and any additional information needed to reach the appropriate decision in a timely manner. This includes both payment and denial of benefits.
- Analyzes complex claims documentation and correspondence in order to process claim transactions, and assists with customer requests to determine appropriate outcomes. Keys and documents data accurately.
- Communicates with external and internal customers to obtain specific claim information in order to finalize claims and to explain claim handling.
- Receives, analyzes and processes incoming claim inquiries and communicates outcomes. Effectively responds to and resolves customer requests by utilizing expanded knowledge and skill sets, systems, policies, procedures, regulations, and other reference available. May handle escalated claim and call requests.
- Provides effective customer service via multiple channels on the phone (to include inbound and outbound calls), written/email, correspondence, etc. Performs service recovery techniques to resolve requests. Provides compliant and easily understood resolution options with the desired outcome of creating a positive customer experience. Utilizes resources to support service delivery resulting in retaining and/or growing the business.
- Meets and/or exceeds department standards related to attendance, productivity and quality
- Makes appropriate referrals to legal, underwriting and special investigations as needed.
- Creates written letters to provide concise explanations to customers regarding claim determinations.
- Actively participates in and seeks out self-development opportunities, exposures and experiences, with a willingness to learn new skills and/or product lines.
- Actively participates in daily management through huddle involvement and the identification and supports implementation of process improvements. Provides insights and recommendations of for enhancements to processes, training and the quality of service delivery to our customers.
- Has a primary focus on customer satisfaction, provides an effective level of customer service.
- Stays abreast of and adheres to Company processes and procedures, industry changes, federal and state legislation and regulations.
- Assists with peer development and delivery/service requirements through information and knowledge sharing, resulting in supporting and resolving customer requests. Assists with the development, delivery and oversight of training and quality auditing program material.
- Develops and maintains effective working relationships with internal and external customers.
- May handle over limit threshold payment approvals based on department guidelines.
- This position requires extensive or prolonged typing/keyboarding.
- This position is in a fast-paced, high volume environment with set production goals.
- This position requires sitting over 66% of the time.
- This position requires Visual Acuity at 20 inches (or less) over 66% of the time.
- Shows a sense of urgency and is accountable for work results.
- Demonstrated ability to adapt to a diverse and changing work environment. Willingness to learn new skills with the ability to multi-task.
- Ability to work independently, and/or as part of a team, in a collaborative environment and is approachable.
- Effective time management and organizational skills with an attention to detail and strong analytical and decision-making abilities.
- Ability to meet deadlines in a fast paced work environment.
- Strong oral, written and interpersonal communication skills, sound judgment and the ability to think within a structured and compliant work environment while focusing on the customer.
- Demonstrated understanding of computer systems such as email, data entry, and Microsoft products, with proficient keyboarding skills.
- Ability to work flexible shifts and maintain regular and predictable attendance with adherence to department and company attendance expectations. May be required to work overtime based on business needs.
- Demonstrated ability to assess and understand the needs of the customer and demonstrates flexibility in customizing approach and response to resolve requests in a respectful and timely manner.
- Ability to diffuse escalated situations when necessary.
- College degree or work equivalent.
- Insurance product knowledge of Business area.
- Experience with the application of policies, practices and procedures in a business environment.
- Knowledge of medical terminology.
- Presentation skills.
If you are a qualified individual with a disability or a disabled veteran, you have the right to request an accommodation if you are unable or limited in your ability to use or access our career center as a result of your disability. To request an accommodation, contact a Human Resources Representative at 1-800-780-0304. We are available Monday through Friday 7 am to 4:30 pm CST.
For all other inquiries, contact our HR Helpline at 1-800-365-1405, option 4.
Mutual of Omaha and its affiliates are an Equal Opportunity /Affirmative Action Employer, Minorities/Female/Disabled/Veteran
To All Recruitment Agencies: We do not accept unsolicited agency resumes and we are not responsible for any fees related to unsolicited resumes.
Advertised: Central Daylight Time
Applications close: Central Daylight Time
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