CLAIMS EXAMINER TRAINEE

Position: Claims Examiner- Trainee Range No: 0801

Revised Date: 10/2021

Job Purpose:

Under direct supervision of the Supervisor, this position will learn to apply techniques to process routine and complex claims, analyze expenditures and make recommendations for third-party liability claims.

Job Duties:

 Work with trainer and/or assigned co-worker to learn and perform review of plan documents and procedures to apply plan provisions, limitations and exclusions when making benefit determinations. 

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 Learn to request information to complete or review claims using standard procedures and letters, and asks questions as needed. 

 Must demonstrate ability to learn and grow with continuous improvement and ability to increase average daily claim production while maintaining accuracy and quality.

 Performs computations and processes claims independently up to the dollar threshold set by the trainer not to exceed the job classification maximum of $1,500.00.

 Learns to perform duties and prepare to become a Claims Examiner by meeting training objectives and expected production metrics. 

 Communicates efficiently by telephone, in writing or in person with all personnel, members, providers, external vendors or others regarding claim benefit questions or information.

 Communicates with the Quality Assurance Supervisor in conjunction with their trainer as necessary to request and receive data on pending claims.

 Learns to apply procedures to third-party liability claim claims.

 Exercises professional judgment on daily tasks and seeks approval from supervisor or trainer when faced with new or unfamiliar tasks.

 Maintain a 10 business-day turnaround time on assigned claim responsibilities.

 Maintain and update a pending file with follow-ups on correspondence as required.

 Ability to meet production and quality goals on a consistent basis as outlined within training.

 Routes claims requiring review to the assigned Claim Adjuster Senior II.

 Demonstrates knowledge of assigned duties as well as the legacy and the recently migrated claims processing system.

 Perform other duties as assigned.

Minimum qualifications:

 6 months or more within a Claims Pre-Processor position Or

6 months in another position with field related experience.

 Working knowledge of basic office equipment.

 Positive interpersonal communications with internal personnel, external clients and vendors.

 Demonstrated ability to keep calm and positive within all communications.

 Proven ability to accurately and timely review and edit documents.

 Utilize computer, phone systems and reference materials to be able to effectively perform the essential functions of the position.

 Previous experience utilizing Microsoft office software.

 High school diploma or G.E.D

Preferred qualifications

 2 years of college experience in a related field

Physical/Mental requirements:

 The physical and mental demands described here are representative of those that must be met by

employees to successfully perform the essential functions of this job.

 While performing the duties of this job, employees are regularly required to use written and oral communication skills; read and interpret data, information and documents; analyze and solve

non-routine and complex office administrative problems; use math and mathematical reasoning; observe and interpret situations; learn and apply new information or skills; perform highly detailed work on multiple, concurrent tasks; work under intensive deadlines with frequent interruptions.

Work environment:

 The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this class. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Employees work under typical office conditions.

 WPAS is an equal opportunity employer. We celebrate diversity and strive to continually create the most inclusive work environment for all our employees.