Claim Reviewer
- Complete quality reviews of internal documentation and systems to determine accuracy of deliverables (e.g. claim or calls).
- Provide guidance and coaching because of quality review findings.
- Professional support role, responsible for specific administrative and/or quality review questions and requests from internal business stakeholder.
- Individuals work under limited supervision.
- Quality review deliverables – e.g. such as claim review (Compliance, business or performance guarantee reviews) or coaching – based on job aids, contracts and other SOPs.
- Reviews the accuracy of case processing activities such as: claim payments to ensure compliance and consistency with administrative procedures and guidelines.
- Executes on appropriate quality methodology by providing consultative services and guidance including quality review methodology, compliance and legal guidelines and business standard references.
- Researches, interprets and responds to inquiries from internal customers or partners (Sales, Account Management or Ops management) regarding product and case-specific issues; such as claim investigation and rebuttals.
- Identifies and communicates review findings that needs to be escalated appropriately.
- Acts as a figure of authority / SME in regard to product knowledge, processes and compliance and legal framework.
- Participates in calibration sessions internally and with business partners including vendors.
- Handles rebuttal requests.
- Manage and/or recommend coaching sessions to address defect and error trends.
- Demonstrates seasoned knowledge of Group Insurance products and processes.
- Champions GBS Quality Review Program to peers and internal customers.
- 3+ Group Insured/STD/Absence product experience required
- 5+ years of relevant related work experience preferred
- Experience in quality control / review preferred
- Ability to understand compliance, legal and complex business processes
- Coaching skills and experience
- Outstanding verbal and written communication
- Forward thinking mindset
- Attention to details, organized, quality and productivity driven
- High School Diploma preferred
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