Claims manager health

Guardian Life Insurance Company; Madison (WI); Remote; USD 49,000 - 74,000; Full time

Job summary

Guardian Life Insurance Company is seeking a Group Life/Supplemental Health Claims Case Manager II to manage and adjudicate claims accurately while providing exceptional customer service. The position requires analytical skills, compliance knowledge, and experience in life claims adjudication. With supportive training and growth opportunities, this role is essential for ensuring policyholders receive timely claim resolutions. Ideal candidates will have a college degree, a strong customer service background, and be skilled in analytical decision-making.

Qualifications

• 2+ years' experience adjudicating life claims required.
• 1+ years' experience processing Supplemental Health claims preferred.
• Strong math aptitude and PC skills required.

Responsibilities

• Make timely and accurate decisions on assigned claims.
• Evaluate and resolve moderately complex cases.
• Document and enter information related to claims processing.

Skills

Analytical skills

Written communication

Verbal communication

Problem solving

Customer service

Education

College degree preferred

Tools

Microsoft Word

Excel

Job description

The Group Life/Supplemental Health Claims Case Manager II is responsible for making timely and accurate decisions on assigned claims through proactive case management according to plan provisions, state and federal guidelines and established protocols. This position will primarily adjudicate Supplement Health Claims but will also be responsible for adjudicating Life Claims. This position utilizes problem solving, analytical, written and verbal communication skills to deliver timely and appropriate life claim decisions while providing superior customer service to all internal and external customers. The Claims Case Manager II administers claims within a variety of group sizes ranging from small (2+ lives) to large market (1000+ lives). The Claims Case Manager II will be responsible for handling claims across our suite of Supplemental Health offerings, including Accident, Hospital Indemnity, Cancer, and Critical Illness. In addition, the Claims Case Manager II will provide support when needed to Life Claims by handling Basic and Optional Group Life claims as well as more complex Accidental Death & Dismemberment (AD&D) Claims, ensuring all plan provisions and eligibility requirements are met by members and/or their dependents prior to approving claim payments. The Life Claims Case Manager II consults with legal, investigative resources, and financial specialists as needed.

New colleagues may receive up to three months of training, depending upon their level of experience. After the training period has been completed, this position is responsible for making all decisions on assigned claims within their designated authority limits.

You are

Ready to grow your career by applying intellectual curiosity while proactively looking at new and different ways of approaching work by displaying technical and functional competence, and expertise!

You will

• Gather claims investigation information, make claims decisions, and handle customer inquiries/problems related to general claims processing (i.e., health, life, disability, annuities, AD&D, critical illness)

• Evaluate and resolve moderately complex cases, utilizing prior experience and guidelines to address and communicate complex resolutions

• Use the information within the medical, financial, and other claim documents to inform the claims adjudication process in more straight-forward claims, escalating as necessary; follow up as needed to address gaps in data and information

• Document and enter information related to the processing of assigned claims (including items such as process, provider number, service, diagnosis codes); reviews and approves assigned categories of claims of moderate complexity and exposure, requiring moderate oversight

• Correspond and communicate complex and sensitive information with customers/plan holders, ensure communications reflect responsiveness, flexibility, empathy, customer focus as well as technical/factual information to drive resolution

• Utilize critical thinking and investigative techniques to issue spot and identify resources needed to assist in making claim determinations while applying factual information provided by the customer.

• Apply and orient learned best practices and regulatory changes to case management and team processes, ensuring that all activities are conducted within legal and regulatory frameworks

You have

• College degree preferred or equivalent work/education experience

• 2+ years' experience adjudicating life claims required

• 1 or more years' experience processing and/or supporting Supplemental Health claims strongly preferred

• Experience in other customer service role(s) a plus

• Regulatory and Compliance experience a plus

• Understanding of medical terminology helpful

• Strong math aptitude skills and PC skills (e.g., Microsoft Word & Excel)

Functional Skills

• Excellent written and verbal communication skills

• Ability to exercise independent & sound judgment in decision making

• Ability to analyze evidence for discrepancies

• Ability to conduct research using multiple techniques

• Excellent time management & organizational skills

• Multitasking with the ability to manage continually changing priorities and ability to prioritize work based on customer service needs and departmental regulations

• Self-motivated & able to work independently

• Ability to work collaboratively with multiple professional disciplines and with diverse population

Location

This is a mobile (remote) position.

Salary Range:

$49,160.00 - $73,737.50

The salary range reflected above is a good faith estimate of base pay for the primary location of the position. The salary for this position ultimately will be determined based on the education, experience, knowledge, and abilities of the successful candidate. In addition to salary, this role may also be eligible for annual, sales, or other incentive compensation.

Our Promise

At Guardian, you'll have the support and flexibility to achieve your professional and personal goals. Through skill-building, leadership development and philanthropic opportunities, we provide opportunities to build communities and grow your career, surrounded by diverse colleagues with high ethical standards.

Inspire Well-Being

As part of Guardian's Purpose - to inspire well-being - we are committed to offering contemporary, supportive, flexible, and inclusive benefits and resources to our colleagues. Explore our company benefits at www.guardianlife.com/careers/corporate/benefits . Benefits apply to full-time eligible employees. Interns are not eligible for most Company benefits.

Equal Employment Opportunity

Guardian is an equal opportunity employer. All qualified applicants will be considered for employment without regard to age, race, color, creed, religion, sex, affectional or sexual orientation, national origin, ancestry, marital status, disability, military or veteran status, or any other classification protected by applicable law.

Accommodations

Guardian is committed to providing access, equal opportunity and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities. Guardian also provides reasonable accommodations to qualified job applicants (and employees) to accommodate the individual's known limitations related to pregnancy, childbirth, or related medical conditions, unless doing so would create an undue hardship. If reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact [e-mail] .

Current Guardian Colleagues: Please apply through the internal Jobs Hub in Workday.

Every day, Guardian helps our 29 million customers realize their dreams through a range of insurance and financial products and services. Our Purpose, to inspire well-being, guides our dedication to the colleagues, consumers, and communities we serve. We know that people count, and we go above and beyond to prepare them for the life they want to live, focusing on their overall well-being - mind, body, and wallet. As one of the largest mutual insurance companies, we put our customers first. Behind every bright future is a GuardianTM. Learn more about Guardian at guardianlife.com .