Group Claims Examiner

Role Overview

• Review and manage Life, Disability, and Waiver of Premium claims, ensuring compliance with company policies and regulatory standards.
• Evaluate waiting periods, verify medical providers and treatment institutions, and assess the reasonableness of fees.
• Determine claim applicability, conduct investigations, and evaluate allowable benefits under policies or certificates.
• Approve claims within assigned authority limits, escalating complex or high value claims as necessary.
• Accurately enter and maintain claims data within the claims management system.
• Gather and verify documentation to ensure timely and accurate claim processing.
• Conduct detailed reviews to validate claim accuracy and identify discrepancies or potentially fraudulent activity.
• Provide prompt, courteous, and professional service to clients, employers, broker partners, and internal stakeholders.
• Communicate effectively with claimants and beneficiaries to resolve inquiries and ensure clarity throughout the claims process.
• Maintain organized, audit-ready claim files that support transparency and compliance.
• Partner with legal, compliance, underwriting, and SIU teams on complex, disputed, or potentially fraudulent claims.
• Ensure adherence to all regulatory requirements, company policies, and service standards.
• Support a consistent and compliant claims handling approach across all lines of business.
• Analyze claims data to identify trends, patterns, and opportunities for improvement.
• Prepare reports and summaries for leadership to support data-driven decision-making.
• Partner with internal teams to improve workflows, reduce cycle times, and enhance claim outcomes.
• Support implementation of new tools, systems, and best practices to improve efficiency and customer satisfaction.
• Stay current on industry regulations, product updates, and compliance requirements.

Requirements

• High School Diploma or GED required
• Bachelor’s degree in a related field or equivalent experience preferred
• 2–4 years of experience in group insurance claims processing or related financial services role
• Strong understanding of insurance policies, claims practices, and regulatory standards
• Proficiency with claims management systems and Microsoft Office applications
• Excellent analytical, problem-solving, and decision-making skills
• Strong attention to detail and ability to manage multiple priorities in a fast-paced environment
• Effective written and verbal communication skills
• Commitment to continuous learning and professional development

Benefits

• Normal office environment
• Periodic travel may be required