Claims Examiner -Medical

Company Name:
Europ Assistance USA
Position Type:
Position Summary
Reporting to the Claims Supervisor, this position is responsible for the verifying the benefits available in the policy, review of travel and medical claims, and research on appropriateness of documents submitted and accurate processing of the Travel Assistance activity related medical and non-medical expenses.
Position Responsibilities
Determines the covered benefits by review of the Log information recorded by Travel Assistance, Procedure Manual or accessing Client database.
Conducts document review by studying provisions of policy or certificate; studying claims documentation provided (HCFA, UB forms or Non Standard Statements, Invoices), supporting documentation.
Reviews services authorized in conjunction with log notes and ordering investigation of questionable claims; approving or returning documentation
Researches and investigates claims with multiple coverage 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
Conducts claim discounting by using the PPO tool
Pursues and follow up on open claims within specified timeframe
Process all claim requests for payment according to contract stipulations, in a timely manner following department and organizational procedures.
Maintain an average score on all audits & individual and team production standards. Keeps up to date on

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