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Summary:
Provides technical expertise for assigned product line(s) in the handling of complex, contestable, sensitive and large benefit amount claims.
Primary Duties & Responsibilities:
- Responsible for providing technical expertise to applicable product line benefits division in the handling of complex, contestable, sensitive and large benefit amount claims. This includes responsibility for claims administration, compliance with applicable laws and regulations, ensuring claim handling standards/best practices and administration of claims in accordance with the company's claim philosophy.
- Uses extensive financial, medical, legal, claims and/or state requirement knowledge to provide technical assistance and direction to the staff in interpreting and analyzing pertinent facts associated with large dollar and contestable claims referrals by claims staff.
- Provides technical, consultation to staff to assist with their review of claims, appeals and complaints.
- Responsible for advanced training, case clinics, rounding, review of claim denials, appeals, depositions and claim settlements
- Provides prompt case review and initiates decisive action on claim approvals, denials and appeals of denied claims referred from the teams.
- Provides advice and direction on claims and where field investigation or negotiation is necessary and may be required to personally meet with the appropriate parties anywhere in the country to resolve the claim.
- Serves as a liaison with the Law Department, initiating and reviewing requests for legal opinions and assisting the staff in the application of legal opinions that are received. This may include assistance in preparing for ADR or litigation and gathering and presenting evidence and/or providing deposition or appearing as a court witness.
- Assists in the continued development of Claims Analysts, Specialists and Consultants by providing technical guidance, training, feedback, recognition and encouraging empowerment, aimed at enhancing their expertise in claims analysis.
- Proactively works to influence and motivate others while creating a climate that fosters customer focus and continuous learning and improvement.
- Participates in other departmental projects and in the department's management of assigned product line(s) claim unit.
- Develops, evaluates, and updates claim processes according to contract language and provisions, state statutes and regulations, and/or HIPAA requirements as applicable.
- Serves as product line subject matter expert for new contract introductions, regulatory routings and projects impacting claims handling.
Qualifications:
- College degree or equivalent combination of education and experience five+ years' experience working with medical and or claims/underwriting.
- In depth knowledge and understanding of the high dollar and contestable claims.
- Ability to think clearly, logically and exhibit sound judgment in high stress situations
- Strong working knowledge of one of more of the following areas: disability income and life waiver of premium claims, death claims or long term care claims, including policies and products, guidelines and regulatory requirements related to the specific product line, .
- Excellent judgment and decision-making skills
- Excellent verbal and written communication skills
- Proven ability to lead others formally or informally, work effectively outside of silos with others, mentor and develop others
- Consummate skill in the techniques of claim administration.
- Ability to analyze multiple facts surfacing in contestable and controversial claims and arrive at a logical conclusion based on those facts.
- Possesses broad to extensive knowledge of medical terminology, legal terminology, familiarity with underwriting principals and procedures, basic accounting principles and other current developments in claim administration
Compensation Range:
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Northwestern Mutual pays on a geographic-specific salary structure and placement in the salary range for this position will be determined by a number of factors including the skills, education, training, credentials and experience of the candidate; the scope, complexity as well as the cost of labor in the market; and other conditions of employment. At Northwestern Mutual, it is not typical for an individual to be hired at or near the top of the range for their role and compensation decisions are dependent on the facts and circumstances of each case. Please note that the salary range listed in the posting is the standard pay structure. Positions in certain locations (such as California) may provide an increase on the standard pay structure based on the location. Please click here for additiona l information relating to location-based pay structures.
We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender identity or expression, sexual orientation, national origin, disability, age or status as a protected veteran, or any other characteristic protected by law.
If you work or would be working in California, Colorado, New York City, Washington or outside of a Corporate location, please click here for information pertaining to compensation and benefits.
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