Insurance

• The Claims Examiner is responsible for reviewing, evaluating, and processing claims in accordance with policy provisions, regulatory requirements, and organizational guidelines.
• This role ensures timely, accurate, and fair adjudication of claims while maintaining a high level of customer service and compliance.
• Review and analyze claim submissions, supporting documentation, and policy details.
• Determine claim eligibility, coverage, and benefits according to company policies and industry regulations.
• Request additional documentation or information as needed to finalize claim determinations.
• Accurately calculate payment amounts and authorize claim settlements.
• Maintain detailed, organized claim files and records in the claims management system.
• Communicate claim decisions clearly to policyholders, providers, or other stakeholders.
• Collaborate with internal departments (e.g., underwriting, legal, provider relations) for complex claim cases.
• Identify potential fraud, waste, or abuse and escalate cases as required.
• Ensure all claims are processed within required timelines and service-level agreements.
• Stay up to date on industry regulations, policy changes, and best practices.

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