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 claims 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 facilitating, 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.
- 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 Alternate Dispute Resolution 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.
- Serves as product line subject matter expert for new contract introductions, regulatory routings and projects impacting claims handling.
Continuous Improvement and Innovation
- Participate in continuous improvement initiatives to enhance claims processes, reduce turnaround times, and improve accuracy.
- Assist with special projects to support the business.
- Embrace and advocate for new technology, educating beneficiaries and field representatives.
- Support digital capabilities and adapt positively to changing environments and new situations.
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
- 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
Required Skills:
- Change Management (NM) - Intermediate
- Attention to Detail (NM) - Expert
- Problem Management (NM) - Advanced
- Learning Agility & Critical Thinking (NM) - Advanced
- Information Gathering (NM) - Advanced
- Data Application (NM) - Advanced
- Claims Acumen (NM) - Advanced
- Coaching & Mentoring (NM) - Intermediate
- Business Acumen (NM) - Intermediate
- Training, Educating & Awareness (NM) - Intermediate
- Change Adaptability (NM) - Advanced
- Adaptive Communication (NM) - Advanced
- Analytical Thinking (NM) - Advanced
- Legal Collaboration (NM) - Advanced
- Prioritization (NM) - Advanced
- Insurance Acumen (NM) - Advanced
- Insurance Contract Management (NM) - Advanced
- Decision Making (NM) - Expert
- Empathetic Communication (NM) - Advanced
- Customer Centricity (NM) - Expert
This position has been classified as an Associated Person under NMIS guidelines and requires fingerprinting and completion of required form.Non-Registered Fingerprinted - FINRA
Compensation Range:
Pay Range - Start:
$76,650.00
Pay Range - End:
$142,350.00
Geographic Specific Pay Structure:
Structure 110:
$84,350.00 USD - $156,650.00 USD
Structure 115:
$88,130.00 USD - $163,670.00 USD
We believe in fairness and transparency. It’s why we share the salary range for most of our roles. However, final salaries are based on a number of factors, including the skills and experience of the candidate; the current market; location of the candidate; and other factors uncovered in the hiring process. The standard pay structure is listed but if you’re living in California, New York City or other eligible location, geographic specific pay structures, compensation and benefits could be applicable, click here to learn more.
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Northwestern Mutual is an equal opportunity employer who welcomes and encourages diversity in the workforce. We are committed to creating and maintaining an environment in which each employee can contribute creative ideas, seek challenges, assume leadership and continue to focus on meeting and exceeding business and personal objectives.