Claims Manager, Job# 0715-20

Claims Manager, Job# 0715-20

Prosperity Service Group, LLC is seeking a Claims Manager. This position manages and directs all activities and functions of the Claims Department with focus on insuring that the quality of claim settlements and service to claimants is performed within standards set by internal time service and guidelines as well as state regulations.  Provide expert guidance in the evaluation and analysis of life, annuity and disability claims.

Essential Duties and Responsibilities include, but not limited to the following:

  • Ensures timely and accurate administration of all individual and worksite claims.
  • Directs the investigation and review of information in connection with contestable claims.
  • Examines, summarizes and approves non-contestable and contestable life, annuity, and disability claims within authorization guidelines or makes recommendations to upper management based on the review of all necessary claim forms or documents, medical records, lab reports, medical reports, police and accident reports and other investigative reports.
  • Authorized to review and approve claims up to $100,000, including reviewing and approving claims for members of the claims team with lower approval authority.
  • Ensure appropriate adjustments to facilitate accurate 1099 and 5498 reporting.
  • Oversee the reinsurance notifications and submit/process requests for reinsurance reimbursements.
  • Daily & monthly oversight of claim reports.
  • Maintain a high degree of knowledge regarding fair claim settlement practices, misrepresentation guidelines, delayed settlement interest guidelines and established claim examination procedures. 
  • Assist examiners in the interpretation of these rules and guidelines.
  • Processes monthly claim and reinsurance reports, working with Finance and Actuary departments to resolve any discrepancies/issues on the reports.
  • Manages problem cases and/or complaints from agents, beneficiaries or claimants.
  • Performs periodic audits on life, annuity, disability and worksite claims.
  • Participates in the development of operating strategy for the administration of claims.
  • Responsible for leading the development of procedures and automation to efficiently process claims resulting from new and existing products.
  • Participate as a project leader or team member for the implementation of new products, systems or process/procedures.
  • Mentor Claim Examiners by conducting training sessions or other technical tasks.
  • Develops, analyzes statistical data to be provided to management regarding experience on individual claims. 
  • Presents and implements recommendations based on compiled data.
  • Maintains current knowledge of industry practices through ongoing review of industry publications, off-site training and industry networking.
  • Monitors daily and monthly statistical reporting and reports to management.
  • Monitors and controls team processing in accordance with quality and time service standards.
  • Establishes team and individual staff goals.
  • Identifies and implements changes to improve workflow efficiency and customer service.
  • Develops, implements and maintains procedures for the Claims Team.
  • Hires, develops and trains the staff necessary to assure adequate resources are available to provide superior and time service.
  • Responsible for completing annual performance evaluations for direct reports.
  • Other duties may be assigned.

Management Responsibilities                                           

Manages multiple employees in the Claims Department.

Carries out management responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include, but not limited to, interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and problem solving.

Education and/or Experience                                            

Bachelor's degree (B.A.) or equivalent combination of education and experience. Minimum of ten (10) years life, annuity or disability claim examination experience, preferred.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Communication and Language Skills  

  • Ability to read, analyze and interpret common scientific and technical journals, financial reports, medical records and legal documents. 
  • Ability to respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community. 
  • Ability to write procedures, memos, emails and training documents that conform to prescribed style and format. 
  • Ability to effectively present information to claims team, project team, upper management and legal.

Mathematical Skills                                                 

  • Ability to calculate figures and amounts such as discounts, interest, commissions, and percentages. 
  • Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.

Competencies

The following competencies are consistent with Prosperity’s core values and apply to all positions:  Learning and applying new skills, using technology to increase productivity, implementing changes to improve performance, adapting to changes in the work environment, and supporting the achievement of team, department and company goals.

Reasoning Ability                                                     

Ability to solve practical problems and deal with a variety of variables in situations where any limited standardization exists.  Ability to interpret detailed instructions furnished in written, oral, diagram, or schedule form.  Ability to develop alternative solutions and apply specific resources or techniques to solve problems.  Ability to draw inferences from partial information. 

Certificates, Licenses, Registrations

ALHC (Associate Life/Health Claims) – Preferred

Other Skills and Abilities                                                    

  • Advanced knowledge of Microsoft Office (Word, Excel, and PowerPoint) and query software. 
  • Must demonstrate the ability to multi-task projects and responsibilities. 
  • This job requires an in-depth knowledge and understanding of medical procedures and terminology to analyze and summarize medical records, lab tests and other medical studies. 
  • The incumbent must have the ability to formulate decisions and recommendations based on these factors as applied to complex life, annuity, disability and worksite claims. 
  • Must have good organizational skills. 
  • Must be able to pay close attention to detail and have exceptional reasoning and decision making skills.

Physical Demand

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel; reach with hands and arms and talk or hear. The employee is occasionally required to stand and walk. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision.

To apply, send resume to [email protected] reference HR Job #0715-20.