The Claims Technical Analyst, in partnership with in-house counsel, provides technical claims guidance,
review and training related to compliance with federal and state regulations and coverage matters.
Essential Duties & Responsibilities
Reviews legislative/regulatory research and updates provided by in-house legal counsel. Ensures the
technical guidance related to legal statues, regulation and/or other requirements impacting claim
practices and processes is communicated and implemented.
Develops and implements claim handling policies and best practices. Identifies changes in claim best
practices and workflows to ensure compliance with federal and state laws and regulations. Performs
compliance audits and file reviews to ensure company is meeting regulatory requirements.
Collaborates with in-house and outside counsel to develop, maintain and update technical guidance
materials to ensure adjusters handling of claims remains in compliance with federal and state regulations.
Reviews and updates form letters and releases to ensure they are in compliance with state requirements
and are properly worded and formatted. Provides review of Disclaimers and Reservation of Rights letters
and does research on coverage matters where needed.
Develops and delivers in partnership with in-house and outside counsel, claims adjuster training and
claims training materials related to compliance and coverage matters.
Handles Medicare compliance related issues and reporting.
Serves as liaison with in-house counsel on Departments of Insurance (DOI) matters to ensure timely
reporting for compliance with governmental and regulatory agencies. Prepares information and/or
reports needed to fulfill compliance request from various DOI. Investigates compliance concerns and
determines corrective measures needed to resolve matter to the satisfaction of the DOI. May assist with
market conduct examinations.
Develops and implements Claims onboarding process for new hires. Collaborates with leaders to create new hire onboarding training schedule and identify needed resources. May conduct individual or group training sessions related to claims business systems and processes. Participates in business projects to achieve desired business objectives. Assists in coordinating and prioritizing various aspects of the project, including planning, communication, execution and completion. Performs other related duties as assigned by management.
Education & Experience
Bachelor's degree; 10 years of insurance or coverage related work; or an equivalent combination of education and experience.
Knowledge, Skills & Abilities
* Ability to perform legal research and provide information in easily understandable format.
* Strong understanding of coverage forms.
* Teaching and facilitation skills.
* Ability to assess training needs and objectives.
* Effectively manage a project or lead.
* Excellent communication skills to work with internal and external business partners, including strong presentation skills.
* Ability to communicate effectively with all levels of the organization.
* Ability to be proactive, a self-starter with the ability to manage time effectively.
* Use critical thinking skills to creatively solve problems.
* Regularly and consistently demonstrates commitment to company values and guiding principles.
* Proficient with Microsoft Word, Excel, Outlook and PowerPoint.
Completion of or working toward AINS, AIC, SCLA or similar designation.
While performing the duties of this job, the employee is occasionally required to reach by extending their hands/arms in any direction; lift to raise or lower objects or move objects from place to place. The employee is regularly required to use fingers to keyboard; grasp to hold onto objects with their fingers or palms; talk to express themselves including conveying detailed or important spoken instruction; hear to distinguish sounds at normal levels (with or without correction) and be able to receive detailed information orally; and move their wrists, hands and/or fingers repetitively. The employee must occasionally lift and /or move up to 10 pounds. Specific vision abilities required by this job include close vision and ability to adjust focus.
Incumbent normally engages in typical office or administrative work. The noise level in the work environment is usually moderate (business office with computers and printers).