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Claim Examiner

Western & Southern Financial Group

Last Updated: 11/27/22

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Job Description

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Claim Examiner in CINCINNATI, Ohio | Careers at WESTERN&SOUTHERN LIFE INS CO (

Summary of Responsibilities:

Examines, investigates and evaluates information from policyholders, attorneys, physicians, hospital personnel, police departments, employers, State Medicaid personnel, funeral homes, Probate courts and other professionals needed to determine the disposition of life, annuity, health and disability claims within authority limits. Benefit and coverage decisions made are susceptible to litigation and/or significant monetary damages. In addition to claim handling, handles second-level support calls from the Client Relationship Center (CRC) and direct customer support to clients and financial representatives. Provides prompt and courteous customer service to external and internal customers and provides job-specific training for new hires in addition to training on specialized processes.

Position Responsibilities:

  • Independently reviews and evaluates claims submitted on the company’s life, annuity, health and disability products. Determines the company’s liability using knowledge of policy provisions, medical terminology, disability duration, state regulations and tax requirements.
  • Assures claim processing and payment procedures for death, cancer, ordinary/industrial accident and health and total and permanent disability claims according to company procedures and meets the appropriate state regulations.
  • Determines proper payees, calculates benefits and releases payments up tp $100,000 on life insurance claims, $300,000 on annuity claims and $10,000 on critical illness claims. On cases requiring management approval, completes claim work and makes recommendations on claim decision.
  • Conducts and controls investigations on contestable, accident, foreign and homicide claims up to $10,000. Exercises independent judgment in defining the nature and scope of the investigation. Selects outside investigation firms when appropriate and manages the costs associated with each investigation. Works directly with our Law Department to draft legal releases, affidavits, authorizations and agreements to settle a claim.
  • Maintains compliance with applicable federal and state laws (e.g., HIPAA) related to privacy, security, confidentiality, and protection of personal information, including, but not limited to, personal health information, financial information, and personally identifiable information.
  • Maintains comprehensive knowledge of state regulations and tax requirements that pertain to fixed annuity and life insurance claim processing.
  • Provides guidance and direction to peers on claim issues including payee problems, accounting discrepancies and transaction errors.
  • Responsible for completing project work as assigned by management. Projects include but are not limited to completing various monthly, quarterly and yearly reports.
  • Handles client support calls, providing prompt and courteous service to internal clients, external clients and financial representatives.
  • Communicates through clear, concise, and well-constructed written correspondence and verbal communication while conducting and receiving telephone calls with clients and company personnel in a professional manner.
  • Performs other duties as assigned by management.
Selection Criteria:
  • Demonstrated knowledge of claims administration including payment options, contract provisions and tax ramifications.
  • Must provide examples from work experience of maintaining a high degree of accuracy and excellent organizational skills associated with high volumes of work and/or multiple duties.
  • Demonstrated knowledge and experience with various claims administration systems and/or processes. Ability to continuously make repetitive motions of the wrists, hands and/or fingers.
  • Demonstrated experience working effectively within a team. Must provide examples from work experience of going beyond the call of duty to assist team members.
  • Demonstrated excellent verbal and written communication skills with the ability to successfully interpret and communicate business needs to internal or external customers in a clear, focused and concise manner. This would include strong telephone communication and etiquette skills.
  • Proven experience adapting and demonstrating flexibility associated with changes to policies/procedures.
  • Demonstrated experience acquiring and assimilating new knowledge and skills. Must be able to cite examples of work experience wherein new skills were applied to complete assigned tasks successfully.
  • Demonstrated experience identifying and resolving problems where independent decision-making and initiative were demonstrated. Must provide examples of working under multiple deadlines and minimal supervision.
  • Demonstrated experience and proven strong analytical skills in identifying and quantifying problems arising from customer, policy/procedural changes, etc., and providing effective recommendations to resolve.
Work Setting:
  • This position works in an office setting and remains continuously in a stationary position for long periods of time while working at a desk, on a computer or with other standard office equipment, or while in meetings.
Educational Requirements:
  • High School diploma, some college work preferred

Computer Skills and Knowledge of Hardware & Software Required:

· Working knowledge of word processing, spreadsheet and Microsoft Office applications.

Certifications & Licenses (i.e., Series 6 & 63, CPA, etc.):

  • LOMA 280 and 290, and 50% completion of ALHC designation (ICA) preferred and/or commensurate experience as outlined in the selection criteria section.

Position Demands:

  • Extended hours required during peak workloads or special projects.

Company Details

Cincinnati, Ohio, United States
Western & Southern Financial Group, a Fortune 500 Company, has over a 130-year heritage of meeting the financial stability needs of our customers — individuals, families, businesses, foundations and nonprofits — with a wide range of insurance, investment and retirement solutions through an ever-growing distribution system.Our family of companies continues to grow and diversify, for...