Consultant

• Review and evaluate supplemental health insurance claims for eligibility, completeness, and accuracy.
• Verify policy information, coverage details, and any applicable endorsements or riders.
• Adjudicate claims using established guidelines and company policies.
• Determine the accuracy of medical coding, diagnostic information, and procedure documentation.
• Request any necessary additional information or documentation from policyholders or healthcare providers.
• Collaborate with the claims team to investigate and resolve any complex or disputed claims.
• Ensure that claims are processed and paid in compliance with industry regulations and internal procedures.
• Update claim status and maintain detailed and accurate records of all claim activities.
• Communicate claim decisions, payment details, and any additional requirements to policyholders and healthcare providers.
• Respond to inquiries and provide exceptional customer service to resolve any claim-related issues or concerns.
• Stay updated on industry trends, regulatory changes, and best practices in supplemental health insurance claims processing.
• Perform quality assurance reviews and mentor other Claims Consultants by providing feedback and identifying development opportunities with staff and management.
• Evaluate current processes for efficiency and effectiveness.
• Provide manager support by assisting with decision making and problem-solving.

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