Claim Examiner

MetLife • Oriskany, NY • 14h ago

Location: Must live within a commutable distance of the Oriskany NY office (Central NY)

In the office once a month for office meetings

Summary of Responsibilities:

Review, research, and investigate pended FEGLI Life claim submission with multiple coverages and complexity to determine if claim is payable in accordance with various policy provisions. If payable, determine eligible payee(s) and payment amount(s). If not payable, develop detailed letter of explanation based on policy provisions and claim documents. Provides customer service with empathy and patience on incoming and outgoing phone inquiries and provides guidance on life claim processes.

Functional Responsibilities:

· Identify and obtain missing information required to evaluate FEGLI life claims and input information into a Power Builder computer claim system computer system

· Interpret policy provisions and manually adjudicate FEGLI Life claims to make claim determinations.

· Work with our customer administrative staff to clarify plan provisions and resolve claim discrepancies.

· Respond to written inquiries from policyholders, beneficiaries, attorneys and families of deceased employees. Provide guidance on claim processes and resolve customer issues swiftly and thoroughly.

· Actively pursue and follow up on open claims within specified timeframe.

· Manage and organize work to meet multiple deadlines and competing priorities to ensure department turnaround and customer satisfaction are met.

· Evaluate life claims to identify claim situations requiring referral to Complex Case Manager Specialist or Claims Quality Specialist.

· Maintain good rapport with internal and external customers by taking ownership and projecting an attitude of service.

· Maintain production and quality standards.

· Keep up to date on FEGLI Life procedures by using the Livelink system and attending required training.

· Use Microsoft Word and Excel to obtain information required to evaluate the life claim.

· Provide high quality, timely service to policyholders, beneficiaries, attorneys, families of deceased employees and administration; resolve customer issues swiftly and thoroughly by offering recommendations and solutions.

· Handle outbound calls needed in regards to FEGLI Life servicing.

· Handle customer escalations from Customer Service Associates and solve customer problems via telephone using sound business judgment.

· Respond to telephone referrals submitted regarding claim issues, research the claim as necessary and provide a response to the customer.

· Process claims within payment authority up to $400,000.

· Maintain production and quality standards.

· Utilize FEGLI claim system on Power builder, Livelink, EDCS, Excel, Microsoft Word, and Accurint, Inventory Tracking Log, Daily Production Database to update and maintain accurate data.

· Interpret policy provisions and manually adjudicate complex FEGLI Life claims to make claim determinations.

· Initiate investigations, employing both company and outside facilities to obtain information to determine validity of FEGLI Life claims. (Such as autopsy reports, toxicology reports, accident reports, location of missing beneficiaries, medical reports, homicide investigations, etc.)

· Coach new Case Manager Specialist on FEGLI Life procedures and workflow.

· Interpret policy provisions and manually adjudicate complex FEGLI Life claims to make claim determinations.

· Provide UAT support for system enhancements.

Typical Qualification and Key Competencies:

· Ability to adjust to multiple demands and shifting priorities.

· Consistently demonstrates the MetLife values.

· Ability to introduce new ideas to improve work processes.

· Directs action towards achieving goals that are critical to MetLife's success.

· Uses knowledge of the business and the industry to make the best decisions, weighing the risks of different courses of action.

· Plans and organizes time and priorities to achieve business results.

· Works collaboratively with others, shares best practices, and assists teammates with work.

· Projects an attitude of service, empathy, and patience to all customers.

· Shares information and engages in candid and open dialogue. Expresses self well in conversations and written documents.

· Takes personal accountability for follow through on customer commitments.

· Strong data entry skills required.

· PC knowledge required. (Microsoft Word and Excel)

· College degree or relevant job experience desirable.

· Ability to work periodic overtime required; can include weekends.

· Confidentiality required.

· Excellent oral and written communication skills.

· Ability to deal with people in stressful situations.

· Analytical ability and good judgment in evaluating life claim submissions.

· Life insurance experience highly desirable.

· Demonstrated outstanding customer service and communication skills both written and verbal.

· Ability to adjust to multiple demands and shifting priorities.

· Desire, willingness and ability to learn and perform in a fast-paced environment.

Dimensions:

Answer 80% of all incoming calls within 30 seconds.

Meet Phone Monitoring customer satisfaction standard.

Process all claim submissions within 5 business days.

Follow up on open claims per call-up guidelines and request required documentation as needed.

Meet quality standards to ensure department and customer guarantees are met.

Meet production standards to ensure unit cost goals are obtained.

Abandonment rate of incoming calls must be less than 3%.

Follow up on open claims per call-up guidelines and request required documentation as needed.

Equal Employment Opportunity/Disability/Veterans

If you need an accommodation due to a disability, please email us at accommodations@metlife.com. This information will be held in confidence and used only to determine an appropriate accommodation for the application process.

MetLife maintains a drug-free workplace.

MetLife

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