Hybrid Medical Claims Consultant – Part Time

at AAA Life Insurance Company

• Job title: Medical Claims Consultant – Part Time
• Job type: Part Time
• Experience level: Mid level, Senior
• Salary: Not specified
• Degree requirement: Postgraduate Degree
• Location requirements: Hybrid, Livonia, United States

About the role

• Medical Claims Consultant providing medical and business expertise for contestable claims decisions. Collaborating with claims team and ensuring compliance with policy guidelines.

Responsibilities

• Serve as a resource to the contestable claims team.
• Review of medical documentation including physician and hospital records, accident reports or other clinical materials.
• Review and understanding of policy language – interpret policy exclusions and endorsements in relation to medical findings.
• Review all contestable claim denials, including those that may have potential to result in litigation.
• Identify inconsistencies or gaps in medical documentation and recommend additional information when needed.
• Assist in determining whether a claim is eligible under policy language and with respect to any supporting medical documentation.
• Provide training for claims examiners on medical topics relevant to claims decision making.
• Collaborates closely with claims examiners, underwriters, legal counsel and potentially third parties to ensure accurate and fair claims decisions.
• Maintain up-to-date knowledge of relevant medical standards, diagnostic/treatment guidelines, and regulatory/industry developments that impact claim adjudication.

Requirements

• Doctorate or Advanced healthcare degree (MD, DO, BA-PA (Physician Assistant Bachelor’s Degree in conjunction with PA certification), PA-C, NP, RN) with demonstrated claim-consulting or clinical review experience
• Clinical experience (min 5-10 years) with a strong familiarity of a broad range of medical conditions, treatments or outcomes
• Excellent ability to interpret and synthesize complex medical records, and to translate findings into actionable claims decisions.

Benefits

• Reasonable accommodation will be made for otherwise qualified applicants as needed to enable them to fulfill these requirements.
• We are committed to ensuring equal employment opportunities for all job applicants and employees.