Group Claims Examiner

The incumbent is responsible for settling all valid claims in an efficient and prompt manner in accordance with assigned quotas and expectations.

Pan-American Life Insurance Group is a leading provider of life, accident and health insurance across the Americas. At Pan-American Life, our employees are our greatest asset. We value the collaborative efforts of our employees and partners, and the confidence of the policyholders whose life and health we protect. It is through this long-standing commitment that Pan-American Life continues to succeed.

POSITION – Group Claims Examiner

JOB SUMMARY

The incumbent is required to provide support towards the successful achievement of operational objectives established for Claims Department. The incumbent is responsible for settling all valid claims in an efficient and prompt manner in accordance with assigned quotas and expectations.

RESPONSIBILITIES

1.       Processing of claims:

• Receive claim submissions and relative documents from customers
• Prepare file, establish and maintain reserves
• Request Medical Consultant to conduct medical investigations
• Review reports to determine extent of coverage as required
• Consult with Supervisor on details of claims as required
• Consult with Medical support personnel on details of claims
• Adjudicate claims in line with established standards
• Follow-up on all pending claims

 2.       Estimates and VOBs

• Completion of dental, vision and medical estimates and verification of benefits

 3.       Payment processing

• Ensure the timely completion of ACH / WT uploads within standards
• Administration of ACH rejects

 4.       Maintain records/file:

• Input/update data entry into claims systems

 5.       Queries, Requests and Reporting

• Prepare/generate statistical reports as required
• Review and resolve assigned queries
• Provide support to all audit requests
• Review outstanding files.

 6.       Perform other duties that may be assigned

QUALIFICATIONS AND EXPERIENCE

• Associate Degree in Business Management, Accounting or similar field
• Two (2) Advanced level passes inclusive of Accounting or equivalent
• Five (5) G.C.E./C.X.C passes including English Language and Mathematics
• Three (3) to Five (5) years’ working experience in a similar capacity would be an asset

Insurance related courses and training programme would be considered an asset.