Serve as a resource to the contestable claims team.
Review of medical documentation including physician and hospital records, accident reports or other clinical materials.
Review and understanding of policy language – interpret policy exclusions and endorsements in relation to medical findings.
Review all contestable claim denials, including those that may have potential to result in litigation.
Identify inconsistencies or gaps in medical documentation and recommend additional information when needed.
Assist in determining whether a claim is eligible under policy language and with respect to any supporting medical documentation.
Provide training for claims examiners on medical topics relevant to claims decision making.
Collaborates closely with claims examiners, underwriters, legal counsel and potentially third parties to ensure accurate and fair claims decisions.
Maintain up-to-date knowledge of relevant medical standards, diagnostic/treatment guidelines, and regulatory/industry developments that impact claim adjudication.

Doctorate or Advanced healthcare degree (MD, DO, BA-PA (Physician Assistant Bachelor’s Degree in conjunction with PA certification), PA-C, NP, RN) with demonstrated claim-consulting or clinical review experience
Clinical experience (min 5-10 years) with a strong familiarity of a broad range of medical conditions, treatments or outcomes
Excellent ability to interpret and synthesize complex medical records, and to translate findings into actionable claims decisions.

Reasonable accommodation will be made for otherwise qualified applicants as needed to enable them to fulfill these requirements.
We are committed to ensuring equal employment opportunities for all job applicants and employees.

Medical Claims Consultant – Part Time

Key skills