Claims Examiner I Supplemental Health

Reliance Matrix; Phoenix (AZ); Hybrid; USD 42,000 - 54,000; Full time

Benefits offered by this job

Annual performance bonus

Generous 401(k) company match

Multiple medical plans with HSA option

Dental and vision coverage

Life & Disability Insurance

Paid Parental Leave & Adoption Support

Hybrid work arrangements for eligible

PTO 20 days + holidays

Job summary

Reliance Matrix is seeking a Supplemental Health Claims Examiner I to evaluate Wellness, Accident, Critical Illness, and Hospital Indemnity claims in a fast-paced environment. You will verify eligibility, calculate benefits, and process payments up to $5,000 while delivering respectful customer service.

The role emphasizes accuracy, confidentiality, and collaboration with the claims team to efficiently resolve inquiries and support policyholders and providers.

Qualifications

• High School Diploma or equivalent is required.
• Associates or Bachelor’s Degree is highly preferred.
• Minimum of one year related claims experience is preferred.
• Strong communication skills are essential.
• Good math and calculation skills are required.
• Proficiency with Microsoft Office and claim systems is desirable.

Responsibilities

• Review Wellness, Accident, Critical Illness, or Hospital Indemnity claims for eligibility.
• Authorize claim payments up to $5,000 in line with policy terms.
• Determine proper payee and verify benefit calculations.
• Provide clear information to claimants and document actions.
• Maintain confidentiality and comply with laws and regulations.

Skills

Communication skills

Claims experience

Analytical thinking

Organization

Attention to detail

Education

High School Diploma or equivalent

Associates or Bachelor’s Degree preferred

Tools

Microsoft Office

Automated claims system

Job description

Job Responsibilities and Requirements

In this role, you will serve as a Supplemental Health Claims Examiner I, evaluating and processing lines coverage handled in the Supplemental Health Claims Department according to applicable law and company guidelines. Claims may include Wellness, Accident, Critical Illness, and Hospital Indemnity benefits. The goal is to consistently pay the accurate amount for each claim in accordance with the contract. This role also provides customer service that is respectful, prompt, concise, and accurate in an environment with competing demands.

KEY RESPONSIBILITIES

*other duties as assigned*

Analysis and Adjudication

Reviews and processes Wellness, Accident, Critical Illness, or Hospital Indemnity claim documents and proofs to verify eligibility based on contractual provisions and premium status within company guidelines and applicable law. Authorizes claim payments up to $5,000. Determines proper payee, verifies the accuracy of benefit amount calculations, and any applicable interest calculations and processes benefit payments up to $5,000. Processes system tasks and pending claims in accordance with department guidelines. Provides payment or denials promptly and in full compliance with department procedures and regulations.

Research

Develops an understanding and working knowledge of products, policies and contracts. Develops an understanding of the applicable contract/policy definitions of disability and relevant provisions, clauses, exclusions, as well as statutory requirements. Reviews medical and applicable information to verify eligibility. Determines proper payee, verifies the accuracy of benefit amount calculations, premium amount calculations under contributory plans, and any applicable interest calculations. Fully investigates all relevant claim issues.

Case Management

Provides clear, concise and accurate information to claimants as well as within the claims administrative system. Creates necessary correspondence for benefit denials, partial denials, or eligibility denials. Manages assigned case load as outlined in Key Measures. Requests any necessary additional information from the policyholder and medical providers, or vendors when needed. Utilizes most efficient means to obtain claim information.

Customer Service

Provides customer service that is respectful, prompt, concise, and accurate in an environment with competing demands. Establishes, communicates, and manages claimant and policyholder expectations. Documents claim file actions and telephone conversations appropriately.

REQUIRED KNOWLEDGE, SKILLS, ABILITIES, COMPETENCIES, AND/OR RELATED EXPERIENCE

• *or equivalent experience gained from any combination of formal education, on-the-job training, and/or work and life experience*Required Knowledge, Skills, Abilities and/or Related Experience
• High School Diploma or equivalent required.
• Relevant Associates or Bachelor’s Degree highly preferred.
• Minimum of one (1) year related claims experience preferred.
• Work experience in decision-making and information analysis.
• Requires excellent communication skills.
• Demonstrated prioritization and organization skills.
• Experience working in confidential/protected identification environments.
• Good math and calculation skills.
• Proficient in Microsoft Office products.
• Prior experience using an automated claim system desirable.
• Ability to Travel: None

PHYSICAL REQUIREMENTS

When used in the description below, the following terms are defined as: “Occasional”: done only from time to time, but necessary when it is performed. “Frequent”: regularly performed; generally an act that is required on a daily basis. “Continuous”: typically performed for the majority of an employee’s shift. Sitting for prolonged periods of time, frequently standing, walking distances up to one mile, bending, crouching, kneeling, reaching, occasionally lifting 25lbs, extensive typing, picking up and holding small objecting and otherwise using primarily the fingers rather than the entire hand. Employee is required to have visual acuity sufficient to perform activities such as preparing and analyzing data and figures; transcribing notes; viewing a computer terminal and extensive reading. Employee is required to have hearing sufficient to understand verbal instruction and answer telephones. Reliance Matrix will provide qualified employees with a reasonable accommodation in accordance with applicable law.

CORE VALUES

• Collaboration
• Compassion
• Empowerment
• Integrity
• Fun

What We Offer

At Reliance Matrix, we believe that fostering an inclusive culture allows us to realize more of our potential. And we can’t do this without our most important asset—you. That is why we offer a competitive pay package and a range of benefits to help team members thrive in their financial, physical, and mental wellbeing.

• An annual performance bonus for all team members
• Generous 401(k) company match that is immediately vested
• A choice of three medical plans (that include prescription drug coverage) to suit your unique needs. For High Deductible Health Plan enrollees, a company contribution to your Health Savings Account
• Multiple options for dental and vision coverage
• Company provided Life & Disability Insurance to ensure financial protection when you need it most
• Family friendly benefits including Paid Parental Leave & Adoption Assistance
• Hybrid work arrangements for eligible roles
• Tuition Reimbursement and Continuing Professional Education
• Paid Time Off – new hires start with at least 20 days of PTO per year in addition to nine company paid holidays. As you grow with us, your PTO may increase based on your level within the company and years of service.
• Volunteer days, community partnerships, and Employee Assistance Program
• Ability to connect with colleagues around the country through our Employee Resource Group program

EEO Statement

Reliance Matrix is an equal opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, national origin, citizenship, age or disability, or any other classification or characteristic protected by federal or state law or regulation. We assure you that your opportunity for employment depends solely on your qualifications.

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