Physicians Mutual Insurance Company

The Claims Team at Physicians Mutual is hiring a Senior Claim Examiner for their Long-Term Care team. This role evaluates and responds to claim service requests for Companies’ customers, medical providers and entitled parties.

ABOUT THE JOB

Responsibilities Include:• Analyzes all claim information received in conjunction with all company products which may include contestable and incontestable Hospital Indemnity, Cancer, LTC, ADB, Hospital Agency and Life products and riders. • Resolves claims in accordance with claim procedures, policy provisions and limitations, policy application, underwriting guidelines, medical conditions, company philosophy and state insurance laws.• Corresponds with insureds, doctors, hospitals, and other third parties to collect data. Processes payment or explains reject decisions to customers through appropriate communication channels. • Confirms validity of contract between the company and Policyowner on Agency issued contracts, processes policy amendments or rescissions when necessary. • Answers correspondence directed to Company President and inquiries from State Insurance Departments. • This position requires continuing education and development of new auditing skills on additional product lines as business needs dictate. Qualifications:• Associate Degree or industry coursework is helpful to be successful in this position.• Approximately 5 years of increasingly responsible auditing experience in Long Term Care, Disability, or Health Insurance is preferred but not required.• Strong written and verbal communication skills are necessary to effectively correspond with Policyowners and other interested parties. Ability to handle complex claim situations. This position does about 60% of their work day communicating with policy holders.• Must possess sophisticated problem solving, decision-making, and organizational skills.• Ability to function effectively in a production environment with high quality work.• Good working knowledge of the function of other departments and their relationship to the claims process.

RESPONSIBILITIES

• Analyzes all claim information received in conjunction with all company products which may include contestable and incontestable Hospital Indemnity, Cancer, LTC, ADB, Hospital Agency and Life products and riders.
• Resolves claims in accordance with claim procedures, policy provisions and limitations, policy application, underwriting guidelines, medical conditions, company philosophy and state insurance laws.
• Corresponds with insureds, doctors, hospitals, and other third parties to collect data. Processes payment or explains reject decisions to customers through appropriate communication channels.
• Confirms validity of contract between the company and Policyowner on Agency issued contracts, processes policy amendments or rescissions when necessary.
• Answers correspondence directed to Company President and inquiries from State Insurance Departments.

QUALIFICATIONS

• Associate Degree or industry coursework is helpful to be successful in this position.
• Approximately 5 years of increasingly responsible auditing experience in Long Term Care, Disability, or Health Insurance is preferred but not required.
• Strong written and verbal communication skills are necessary to effectively correspond with Policyowners and other interested parties.
• Must possess sophisticated problem solving, decision-making, and organizational skills.
• Ability to function effectively in a production environment with high quality work.
• Good working knowledge of the function of other departments and their relationship to the claims process.

OTHER

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