MetLife

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.