Claims Trainee

HRMP, a Jencap company, is a third-party administrator for risk takers and is uniquely positioned to offer business solutions to carriers, reinsurers, and underwriters. We provide a variety of services and solutions within the insurance market such as stop-loss program administration, group life and medical conversions, auditing services, back office or run-out administration, quota share and excess medical reinsurance. 

Incumbent learns through self-study, in the classroom, and on-the-job to adjudicate medical stop loss insurance claims. Skills developed include confirming eligibility, determining insurance coverage, examining and resolving medical stop loss claims, documenting actions, maintaining quality customer service, and ensuring compliance.  Over time, the role will include interactions with administrators, MGUs, and brokers.

RESPONSIBILITIES: 

• Navigate assigned systems
• Process/review 50% notifications
• Upload Claims
• Review/Study Summary Plan descriptions [SPD’s} and Stop Loss Policies
• On-line introduction courses related to HIPAA, CA Fair Claim Practices and Fraud and other courses as needed
• Work directly with the senior claims analyst in reviewing medical documentation presented
• Requests additional documentation from sources such as (administrator, broker, hospital, physician, group etc.)
• Adjudicates claims in medical stop loss system, approving, pending, or denying based on compliance with SPD and Stop Loss Policy
• Maintains quality client service by responding timely and accurately to client inquiries
• Maintaining client expected turn-around time
• Ability to follow both written and verbal instructions
• Ability to communicate effectively with others.
• Complete Dean Vaughn Medical Training
• Complete HIA Designation (Within 15 months)
• Earn NY State Independent Adjustor’s License within 2 years
• Performs other duties as assigned

KNOWLEDGE AND SKILLS REQUIRED: 

Documentation skills, data entry skills, analyzing information, problem solving, verbal and written communication, and client focused. Flexibility to handle multiple priorities while maintaining high level of professionalism. Proficiency using Microsoft Office Products (especially excel). Must be able to multi-task and work well initially in a team environment.