Claims Adjudicator / Assessor
Metlife Alico Insurance Company
Total years of experience :2 years, 11 months
• Independently reviews and adjudicates complex or specialty claims for individual or group policies for living and non-living benefits.
• Determines whether to suspend, reject or pay claims within established policies and procedures.
• Compares claim application and/or provider statement with plan file and other records to evaluate completeness and validity of claim.
• Analyzes and answers inquiries regarding claim adjudication, including method of payment, co-pay or deductible amounts, and or reason for denial.
• Analyzes claims to determine extent of liability and settles claims with claimants in accordance with policy provisions.
• Adjusts claims that have been denied, overpaid or underpaid. Routes claims requiring additional information or high-level decision-making. Researches claims and appeals as needed.
• Requests information from internal or outside sources to ascertain completeness and validity of claim including coordination of benefits information.
• Corresponds with agents and claimants to correct errors or omissions on claim forms, and to investigate questionable entries.
• Responds to agents and claimants’ telephone inquiries on the status of claims and adjusts claims as required.
• Coordinate to the insured’s attending physician for verification of claims’ authenticity.
• Makes follow-up for the completion of the requirements in order to finalize the claim.