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 additional information or documentation from policyholders or healthcare providers
• Collaborate with the claims team to investigate and resolve complex or disputed claims
• Ensure 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 additional requirements to policyholders and providers
• Respond to inquiries and provide exceptional customer service to resolve claim-related issues
• Perform quality assurance reviews and mentor other Claims Consultants
• Evaluate current processes for efficiency and effectiveness and provide manager support

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