Claims Examiner

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CLAIMS EXAMINER

Summary
The Claims Examiner directs and coordinates activities involving claims.

Essential Duties and Responsibilities
Essential duties and responsibilities include but are not limited to:

1.    Directs activities of workers investigating claims to ascertain validity of claims.
2.    Processes claims for which company is liable and negotiates settlements.
3.    Reviews incident reports to determine compensation.
4.    Authorizes payment of compensation according to state or federal acts.
5.    Contacts medical personnel to ascertain need for extension of payments beyond specified recovery date.
6.    Negotiates with persons having valid claims.

Supervisory Responsibilities
This job has no supervisory responsibilities.

Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1.    Education and/or Experience: High school diploma or general education degree (GED); or one to three months related experience and/or training; or equivalent combination of education and experience.
2.    Certificates, Licenses, Registrations: None required.
3.    Other Qualifications:
a.    Two years experience in HMO, customer service, data entry, and general office background.
b.    Bi-lingual (English/Spanish) preferred.

Skills and Abilities

1.    Language Skills: Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of the organization.

2.    Mathematical Skills: Ability to add and subtract two digit numbers and to multiply and divide with 10s and 100s. Ability to perform these operations using units of American money and weight measurement, volume, and distance.
3.    Reasoning Skills: Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to deal with problems involving a few concrete variables in standardized situations.
4.    Computer Skills: Strong computer skills.
5.    Other Skills and Abilities:
a.    Excellent data entry.
b.    Excellent communication skills.
c.    Good telephone techniques.

Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1.    While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear.
2.    The employee is frequently required to walk; stand; reach with hands and arms.
3.    The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl.
4.    The employee must occasionally lift and/or move up to 20 pounds.
5.    Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Working Environment
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1.    The noise level in the work environment is usually moderate.
 
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