Ready to take the next step in your career? Maybe you’re looking for advancement opportunities, a better work-life balance, or just something new and exciting.

At Pekin Insurance, we strive to go Beyond the expected® in everything we do.

Position Overview

The Claim Analyst investigates, analyzes, and determines the extent of liability concerning Life and/or Health product lines in order to complete all assigned claims. This position provides excellent customer service to all types of consumers, calculates benefit payments, and issues payment of claims within a certain monetary limit.

Essential Job Functions

• Settles assigned claims while adhering to turnaround and accuracy audit requirements
• Corresponds with necessary parties in various formats, interprets policy provisions, applies appropriate coverage, and obtains/evaluates necessary claim documentation
• Determines legal liability and appropriate payee, applies cost containment measures, identifies applicable subrogation opportunities, and identifies/reports potential fraud
• Reviews medical records and preapproval or predetermination requests as applicable
• Uses discretion and independent judgment to determine coverage and make decisions considering the organization’s risk exposure
• Identifies red flags and understands when to take steps to mitigate risk or consult with management, legal counsel, medical specialists, and/or other parties
• Understands and enforces state and federal legislation in addition to policy provisions, adhering to all necessary regulations, including but not limited to the Employee Retirement Income Security Act of 1974 (ERISA), Affordable Care Act (ACA), and other state statutes
• Understands and communicates appropriate policy settlement options for taxable and nontaxable accounts when applicable and researches additional information as needed
• Investigates claims and works with outside vendors to assist with investigations as needed, including contestable claims, manner of death verification, beneficiary applicability, pre-existing conditions, and medical necessity peer reviews
• Assists with claims and provides related information pertaining to stop loss and/or reinsurance contracts and identifying/reporting high dollar claims
• Attends agent meetings, employer meetings. or other company events as requested
• Assists with claims across multiple product lines, as requested
• Holds check authority up to $15,000 dependent upon experience, audit performance, and product lines
• Handles highly sensitive protected health information (PHI) in a confidential manner
• Performs other duties as assigned

Education & Experience

Required

• Bachelor’s degree in insurance or business-related field or equivalent experience
• Typically requires 1-3 years of experience in related field

Preferred or Specialized

• Prior claim experience

Certifications & Licenses

• Life and/or health designation preferred

Knowledge, Skills & Abilities

Demonstrated ability to:

• Communicate effectively in both oral and written form
• Analyze, organize, and prioritize work while meeting multiple deadlines
• Work as a team member and follow directions
• Recognize, analyze, and solve a variety of problems
• Exercise sound judgment in making critical decisions
• Process and handle confidential information with discretion
• Understand complex policies and procedures
• Read and interpret insurance policy language and various state or federal regulations
• Foresee and minimize risk to the organization
• Handle difficult and stressful situations with professional composure

Demonstrated skill in:

• Completing assignments accurately and with attention to detail
• Customer service

Basic knowledge of:

• Microsoft Office software
• Medical, pharmaceutical, and other health service practices and terminology, along with understanding of health care billing practices and procedures
• Life insurance industry and terminology within specialized product lines