Life Claims - Examiner

Description and Requirements
Basic Function
The process consists of Review, research, and investigate pended Group Life claim submission with multiple coverages and complexity to determine if claim is payable in accordance with various policy provisions, manage Call-ups and outreach to groups for missing information.
Essential Functions (The key deliverables of the role will include but will not be restricted to the details below )
• Identify and obtain missing information required to evaluate Group life claims and input information into a Windows based computer system (BIOS).
• Interpret policy provisions and manually adjudicate Group Life claims to make claim determinations.
• Work with our customer administrative staff to clarify plan provisions and resolve
• claim discrepancies.
• Respond to written inquiries from policyholders, beneficiaries, attorneys and families of deceased employees. Provide guidance on claim processes and resolve customer issues swiftly and thoroughly.
• Actively pursue and follow up on open claims within specified timeframe.
• Manage and organize work to meet multiple deadlines and competing priorities to ensure department turnaround and customer satisfaction are met.
• Evaluate life claims to identify claim situations requiring referral to Senior Examiner.
• Maintain good rapport with internal and external customers by taking ownership and projecting an attitude of service.
• Maintain production and quality standards.
• Keep up to date on Group Life procedures by using the Institutional Life Claims Library and attending required training.
• Use Microsoft Word and Excel to obtain information required to evaluate the life claim.
• Provide high quality, timely service to policyholders, beneficiaries, attorneys, families of deceased employees and administration; resolve customer issues swiftly and thoroughly by offering recommendations and solutions.
• Handle outbound calls needed in regard to Group Life servicing.
• Handle customer escalations from Reviewers and solve customer problems via telephone using sound business judgment.
• Respond to telephone referrals submitted regarding claim issues, research the claim as necessary and provide a response to the customer.
• Process claims withing Payment authority
• Maintain production and quality standards.
• Utilize BIOS, GLIF Production, CDF, Calligo, EDCS, Groupfacts, WorkDesk, NetView and Accurint to update and maintain accurate data.
• Interpret policy provisions and manually adjudicate Group Life claims.
• Initiate investigations, employing both company and outside facilities to obtain information to determine validity of Group Life claims. (Such as autopsy reports, toxicology reports, accident reports, location of missing beneficiaries, medical reports, homicide investigations, etc.)
• Mentor new Claim Examiners on Group Life procedures and workflow.
• Provide UAT support for system enhancements.
• Update & maintain day to day Workforce Management
• Preparing, Reporting & Analyzing the scorecards of performance
• Rules-based Decision Making
• Customer Relationship Management
• Identify possible alternative solutions and select the most appropriate ones
• Extracting data from various sheets and preparing custom defined reports
• Review/generate reports to monitor performance.
• Monitor transactions on an ongoing basis and take corrective steps where necessary or make incremental improvements.
• Provide coaching and feedback to team members to enable them to improve their performance.
• Assist new hires such that they are productive on the floor in the shortest possible time frame.
• Handle customer, employee, and internal partner escalations.
• Client Interaction, where required at the level of supervisors.
• Ensure compliance with internal policies and procedures, external regulations, and information security standards.
• Ensure that all agents in their process know their goals and how they are linked to the Organization's quality policy.
• Motivate team members, anticipate staffing needs, acquire talent for the future, and manage attrition.
• Provide coaching and feedback to team members to enable them to improve their performance to raise individual and organizational capabilities.
• Effectively manage research/resolution/follow-ups for closure of open items.
• Build relationship with Onshore Management to ensure a "one-team approach".
About MetLife
Recognized on Fortune magazine's list of the 2024 "World's Most Admired Companies" and Fortune World's 25 Best Workplaces™ for 2024, MetLife , through its subsidiaries and affiliates, is one of the world's leading financial services companies; providing insurance, annuities, employee benefits and asset management to individual and institutional customers. With operations in more than 40 markets, we hold leading positions in the United States, Latin America, Asia, Europe, and the Middle East.
Our purpose is simple - to help our colleagues, customers, communities, and the world at large create a more confident future. United by purpose and guided by empathy, we're inspired to transform the next century in financial services.
At MetLife, it's #AllTogetherPossible . Join us!
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