Department of Insurance, Financial Institutions & Professional Registration
  • 31-Aug-2017 to 30-Oct-2017 (CST)
  • Jefferson City, MO, USA
  • STARTING ANNUAL SALARY: $35,640 - $38,304 (commensurate with education and experience)
  • Salary
  • Full Time

Missouri State Employees' Retirement System (Defined benefit plan), Major Health Insurance, Dental, Vision (provided for employees and available for families), Paid Life Insurance (amount equivalent to annual salary), Long-Term Disability Insurance, Cafeteria Plan, Deferred Compensation Plan, 12 paid holidays per year, 10 hours of annual leave per month, 10 hours of sick leave per month, Credit Union,


Insurance Consumer Complaint Specialist I (Health)

STARTING ANNUAL SALARY: $35,640 - $38,304 (commensurate with education and experience)

The Missouri Department of Insurance, Financial Institutions and Professional Registration, Division of Consumer Affairs, has a full-time position located in Jefferson City, Missouri.

This position is responsible for responding to inquiries and complaints from the general public and reviewing claim and benefit handling to ensure health plan compliance with federal and state laws and regulations. An employee in this position will have a specialization or concentration in health insurance or health benefit plans with considerable experience with either or preferably both fully insured or self-insured health benefit plans. An employee in this position is assigned to the Life and Health Unit of Consumer Services Section and is responsible for reviewing consumer complaints as to health coverage from both insurance companies and self-insured employer groups, and corresponding with company officials to communicate areas of non-compliance or deficiencies in coverage or claims handling.  Employees refer more complex questions to higher level staff.  The employee will advocate on behalf of the consumer as to issues of coverage or claims denial.  The employee will assist consumers in filing first and/or second level grievances with the health plan.  In addition, the employee will review medical records and information and prepare consumer files for external review by an Independent Review Organization (IRO).   Until the more technical phases of the work are learned, the employee works under close supervision; thereafter, the employee is required to exercise judgment in the performance of assigned responsibilities. General supervision is received from the Life & Health Unit Manager.

EXAMPLES OF WORK PERFORMED: Investigates and responds to consumer inquiries and complaints regarding insurance claims procedures, policy provisions, claim denials, billing practices and services; enters complaint information into computer system. Complaints and inquiries include all communications with consumers in person, via telephone, electronic mail or fax, or in writing.  Reviews and analyzes data to determine validity of complaints and to ensure insurance company compliance with contract requirements, state insurance laws, rules and regulations; refers cases of non-compliance to legal staff with recommendations for action or sanctions. Assists consumers of fully insured or self-insured health plans with first and/or second level grievances. Reviews and analyzes medical and claim information to determine eligibility for external review; prepares file for referral to external review organization and prepare all related documents and correspondence.  Requests documentation, information and assistance from insurance companies or medical providers; serves as liaison and attempts to resolve disputes between complainants and insurance companies or health plans. Refers complaints involving suspected insurance agent fraud to investigative staff; assists in gathering evidence of unacceptable agent practices, as necessary. Refers complaints involving violations of federal law(s) to the appropriate federal agency; tracks the resolution of such referrals.  Maintains records of the investigation and resolution of consumer complaints and inquiries. Performs other related work as assigned.

EXAMPLES OF REQUIRED KNOWLEDGES, SKILLS, AND ABILITIES: Working knowledge of insurance industry and health plan practices, claims processing and complaint procedures. Working knowledge of state laws, rules and regulations, and court decisions affecting health insurance or health coverage. Specific knowledge of health insurance, health coverage and the types of health plans, policies and products offered to Missouri consumers. General knowledge of health benefit or insurance terminology, medical terminology and basic knowledge of provider billing practices. Ability to interpret and explain insurance company policies and practices. Ability to review claims documentation and research complex medical issues.  Ability to communicate effectively and to prepare clear and concise reports. Ability to analyze facts and present logical solutions to problems. Ability to establish and maintain effective working relationships with other employees, consumers, insurance company representatives, state and federal officials. Ability to communicate with consumers in a courteous, polite and professional manner and accurately answer questions about state and federal laws as they pertain to health coverage and claim issues.  Ability to operate a computer and utilize a variety of computer software.

EXPERIENCE AND TRAINING QUALIFICATIONS: Graduation from an accredited four-year college or university with specialization in insurance, risk management, business or public administration, social sciences or closely related areas OR four years of professional or technical experience in insurance, investigations or public relations, of which two years must have been in one or more of the areas listed below; and possession of a high school diploma or a GED certificate.

AREAS OF QUALIFYING EXPERIENCE:

  1. Experience in health insurance underwriting, contract development, agency management, sales, or in processing health insurance claims in a hospital, medical office, insurance company or closely related health insurance experience.
  2. Experience in insurance complaint investigations, civil or criminal investigations, or comparable investigatory experience.
  3. Experience in processing consumer complaints in a public or private setting.
  4. Experience in an insurance regulatory agency which involved interpretation, application and/or enforcement of statutes and regulations.

 Application Process: If interested, please apply online at http://difp.mo.gov/jobs and view current job opportunities. Once on the webpage, complete the "Apply Now" information to the right, then click "Apply for this Position". This will direct you to the online application. You should also submit a current resume and any college transcripts by attaching the documents to the application. 

AN EQUAL OPPORTUNITY EMPLOYER

Department of Insurance, Financial Institutions & Professional Registration
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