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Third Party Liability Examiner I - ROC


Posted: 10/2/2019
Job Reference #: 5000421983306
Categories: Other/General

Job Description

Employment Type

Full Time - Regular-On-Contract

Exempt or Non-Exempt


Job Summary

Investigate potential Third Party Liability cases to determine primacy and ensure correct application of benefits and cost avoidance.

Minimum Qualifications

**Regular on Contract position until one year from date of hire**

  1. Associate's degree and 2 years of work experience dealing directly with the public, including at least 1-year of work experience as a claims examiner or administrative professional; or equivalent combination of college or technical school education, training, and/or experience.
  2. Successful completion of TPL Examiner training program, approximately 12 months in length. Achievement of a minimum 90% accuracy rate on examinations at the end of each of four (4) training modules; this a condition of employment.
  3. Ability to read, analyze, and interpret business documents such as HMSA's plan certificates, documents from governmental regulatory agencies, Blue Cross Blue Shield Association documents, communication from attorneys, Personal Injury Protection forms or other communication from carriers, and Independent Medical Evaluations.
  4. Ability to compose clear, complete and professional correspondence to internal and external customers.
  5. Ability to communicate verbally with internal and external customers in a clear, complete, and professional manner.
  6. Ability to speak effectively before a group of employees and various levels of management.
  7. Ability to Calculate figures and amounts such as discounts, interest, proportions, and percentages using whole numbers, common fractions, and decimals.

Duties and Responsibilities

  1. Investigate potential Third Party Liability (TPL) cases by contacting members, providers, attorneys, and other carriers for necessary information to determine primacy. Utilize and correctly interpret information from multiple systems, databases, training documents, reference manuals, Plan Guide to Benefits, regulations, etc. for data and information to make case determination. Apply TPL polices and/or regulations appropriately to cases with different variables. Manage and update case as appropriate until closure. May be assigned cases that were started by other examiners.
  2. Service internal and external customers via telephone or correspondence in a prompt, accurate, and professional manner on a routine and on-demand basis.
  3. Utilize claims processing system to correctly apply plan benefits based on case determination while maintaining all corporate timeliness and accuracy requirements. Compose correspondence to recover erroneous benefit payments relating to TPL cases.
  4. Attend and successfully complete training as assigned by management.
  5. Other duties as assigned.