Job Summary: 

• Evaluate and assess the cutover from an operations perspective.
• Review or validate issues that surface during cutover
• Maintain updated records and prepares required documentation that may be needed from providers/policyholder.
• Assist in controlling the cost of processing claims.
• Ensure that quality and volume standards are being met and maintained.
• Utilizing and following all policies and procedures are being upheld.
• Evaluates liability and communicates company position to the party responsible for causing damage to company property, or their insurance carrier.
• Coordinates assigned litigation and assists outside counsel with respect to property damage claims.
• Resolves property damage claims within limits of experience and ability and has accountability within a designated authority.
• Represents the Company in Small Claims Court litigation involving facilities damage claims.

Skills on Resume:

• Operational Assessment (Hard Skills)
• Issue Validation (Hard Skills)
• Record Maintenance (Hard Skills)
• Cost Control (Hard Skills)
• Quality Assurance (Hard Skills)
• Policy Adherence (Hard Skills)
• Liability Evaluation (Hard Skills)
• Litigation Coordination (Hard Skills)

Job Summary: 

• Analyzes medical claims and reviews billing information for correctness and completeness.
• Reviews medical billings for the reasonableness of tests, procedures and hospital stays.
• Refers medical claims for further investigation when more information is necessary or when claims are not medically reasonable.
• Identifies inaccuracies of paid claims and works with third-party billers to resolve claims paid in error.
• Submits data to CMS to ensure compliance with all PACE and Medicare Part D reporting requirements in the Health Plan Management System (HPMS).
• Stays up-to-date on PACE Health Plan Operations and Medicare Part D changes through HPMS notifications and the national PACE Association Part D Conference calls.
• Acts as liaison between the insurance carriers and insurance broker 
• Maintain loss expenses reserves that are reflective of the company’s exposure.
• Assist in manual claim entry and member reimbursement
• Receive 400-600 PODs (Proof of Delivery) daily and push through complete PODs

Skills on Resume:

• Medical Claims Analysis (Hard Skills)
• Billing Review (Hard Skills)
• Investigative Referral (Soft Skills)
• Claims Resolution (Hard Skills)
• Regulatory Compliance (Hard Skills)
• Industry Knowledge Update (Soft Skills)
• Liaison Role (Soft Skills)
• Data Management (Hard Skills)

Job Summary: 

• Apply federal and state laws and regulations to ensure compliance across regulations and programs
• Communicate and present trends, findings, and recommendations
• Maintain positive working relationship with the client, colleagues, and partners.
• Foster an attitude of information sharing and open discussion among colleagues.
• Complete claims adjustments and process member receipts
• Meet quality and production standards
• Reviewing all evidence to support a claim.
• Investigate to determine company liability and processing claims/ rebuttals.
• Responsible for verifying claims and contract of carriage.
• Taking customer calls, responding to e-mails, etc.

Skills on Resume:

• Regulatory Compliance (Hard Skills)
• Data Presentation (Hard Skills)
• Client Relations (Soft Skills)
• Team Collaboration (Soft Skills)
• Claims Adjustment (Hard Skills)
• Quality Standards (Hard Skills)
• Evidence Review (Hard Skills)
• Claims Investigation (Hard Skills)

Job Summary: 

• Work with non-profit and state agencies to collect documentation 
• Verify spending and participant enrollment.
• Review documentation to make sure it is complete and accurate.
• Use Microsoft Excel and Access to analyze financial and programmatic data and calculate eligible spending.
• Developing and executing methodologies for calculating allowable costs
• Creating intermediate/advanced formulas and queries in Microsoft Excel and Access.
• Assist non-profit and state agencies in completing required forms
• Train partner agencies on policies and procedures
• Perform quality assurance to make sure that costs are eligible and calculated correctly.
• Build and maintain familiarity with federal and state laws, regulations, related to applicable programs

Skills on Resume:

• Document Verification (Hard Skills)
• Data Analysis (Hard Skills)
• Methodology Development (Hard Skills)
• Training Development (Soft Skills)
• Quality Assurance (Hard Skills)
• Regulatory Knowledge (Hard Skills)
• Collaboration (Soft Skills)
• Stakeholder Engagement (Soft Skills)

Job Summary: 

• Examine and validate electronic and paper claims, including adjustments, Non Par, C.O.B. and M.S.P. and other categories of claims as applicable, in a timely and accurate manner. 
• Prepare claims until its validation process for providers and members, on denial or adjusted claims. 
• Research and document results of claims either for special consideration, conditions or additional data. 
• Interface with personnel of the different areas of the Department to ensure the resolution of problems around the claims, such as, correct validation, and timely payment services. 
• Report any problem that may affect the claims process. 
• Alert a Claims Supervisor for all situations by QNXT System that can affect a complete processing cycle of claims. Special projects 
• Participate with the Claims Supervisors in the preparation of recommendations or guidelines oriented to approach the resolution of claims. 
• Participates in the research, validations and resolution of claims.
• Comply with established quality metrics and production targets.
• Review and analyze PODs ensuring accurate information is recorded into system (Bluejay)

Skills on Resume:

• Claim Validation (Hard Skills)
• Claim Preparation (Hard Skills)
• Claims Research (Hard Skills)
• Interdepartmental Liaison (Soft Skills)
• Issue Reporting (Soft Skills)
• System Alert Management (Hard Skills)
• Resolution Strategy Participation (Soft Skills)
• Quality Compliance (Hard Skills)

Job Summary: 

• Research chargebacks/ disputes, gather supporting evidence and process written correspondence to recover funds for PayRetailers’ merchants.
• Partner and readily collaborate with other stakeholders to solve complex dispute cases (Support, Legal, Financial Partners, etc.)
• Ensure accurate ticketing and resolution for each dispute, from case intake to case closure. 
• Handle follow-up actions based on case outcome.
• Analyze transactional data from different sources and ensure an appropriate resolution is made for each dispute case.
• Resolve end-customer queries regarding failed or pending transactions.
• Review and resolve transactions with alerts.
• Proactively look for ways to improve internal processes.
• Communicate with carriers for missing PODs and record details into system
• Research and resolve discrepancies regarding claims still on hold

Skills on Resume:

• Dispute Resolution (Hard Skills)
• Collaborative Problem Solving (Soft Skills)
• Case Management (Hard Skills)
• Data Analysis (Hard Skills)
• Customer Service (Soft Skills)
• Alert Management (Hard Skills)
• Process Optimization (Soft Skills)
• Communication and Documentation (Soft Skills)

Job Summary: 

• Checking and registering loss advice, cash-loss requests, and technical accounts which are within the scope of the assigned accounts
• Reviewing, analyzing incoming loss information from clients
• Assessing the appropriateness and accuracy of the exposures as presented. 
• Responsible for establishing and/or recommending the appropriate reserves.
• Interacting within the claims team and other internal business partners, including Underwriters and Actuaries, as well as external business partners including brokers and clients.
• Preparing and organizing information and data which are necessary for management reports on a daily, weekly, or quarterly basis ensuring proper communication of developments and issues to internal management and business partners
• Administration of claims within department policies utilizing the various department systems
• Participating in regular data quality checks

Skills on Resume:

• Loss Registration (Hard Skills)
• Data Analysis (Hard Skills)
• Exposure Assessment (Hard Skills)
• Reserve Management (Hard Skills)
• Interdepartmental Communication (Soft Skills)
• Report Preparation (Hard Skills)
• Claims Administration (Hard Skills)
• Data Quality Assurance (Hard Skills)

Job Summary: 

• Collaborate and partner with assigned Product Segment's  Sales Team in the overview & control the Customer Promotion budgets, mechanics and settlement.
• Direct Coordination of Claims-Related Issues with Samsung Customers & Product Segment's Sales Team
• Monitoring and achievement of Claim Lead Time metrics (Marketing Coop and Sales Deduction)
• Monitoring of Claims KPIs(Key Performance Indicators)
• Implementation and Monitoring of Claim Lead Time Process Improvements 
• Timely resolution of claims-related issue
• Topline monitoring of pending claims, settlement status, resolution of issue
• Provide analysis of approved programs after execution to properly assess ROI & provide recommendations for improvements
• Approval and monitoring of Customer Promotions to ensure that it is within allocated budget and applicable Company guidelines and Local tax regulation, Customer Promotion System approval/ maintenance
• Provide guidance to Sales for the alignment of promotions to SEPCO policies and local tax regulations

Skills on Resume:

• Budget Management (Hard Skills)
• Claims Coordination (Hard Skills)
• KPI Monitoring (Hard Skills)
• Process Improvement (Hard Skills)
• Collaborative Partnerships (Soft Skills)
• Analytical Reasoning (Hard Skills)
• Regulatory Compliance (Hard Skills)
• Guidance Provision (Soft Skills)

Job Summary: 

• Cross train and provide oversight of workers’ compensation claims on an as needed basis.
• Prepares Job Aids and FAQ’s for commonly used tasks and functions in the role.
• Tracks unemployment claim fiscal year activities in line with budgetary goals, objectives and cost saving initiatives.
• Reviews, approves and submits for payment all claim, claim services and unemployment invoices.
• Partners with internal and external resources to aid in efforts toward streamlining CPS claims handling processes to eliminate redundancies.
• Remains current with and adheres to best claim practices for return-to-work methodology.
• Reviews the audit and quarterly charge statements (BEN 118R) with vendor and management to evaluate cost containment progress and strategies.
• Collaboration with Customers to converge their claims process with process
• Review claims to ensure compliance with established claim entry and claim payment policies and procedures
• Review and release pended claims

Skills on Resume:

• Cross-Training (Hard Skills)
• Resource Development (Hard Skills)
• Budget Tracking (Hard Skills)
• Invoice Management (Hard Skills)
• Process Streamlining (Soft Skills)
• Regulatory Compliance (Hard Skills)
• Cost Containment Analysis (Hard Skills)
• Stakeholder Collaboration (Soft Skills)

Job Summary: 

• Acts as liaison between the unemployment claims handling vendor, CPS employees, Equal Opportunity Compliance Office (EOCO), Administration and school communities
• Gather supportive details in order to make sufficient determinations on separation claims.
• Provides oversight of unemployment claims to include attending telephonic administrative hearings, preparing responses to grievances and maintaining required filings to the state of Illinois
• Stays up to date on claims assigned and team metric performance goals.
• Reviews all determinations, files 1st and 2nd level appeals.
• Provides prep sessions and post-hearing consultations for hearings. 
• Maintains integral knowledge and working relationships with external and internal business partners (IDES, Payroll, Finance, Accounts Payable, IT, Vendor).
• Remains current on any UI legislative changes to assist management with drafting and the distribution of all staff communications.
• Assists in the training of team coordinator on assigned duties and responsibilities.
• Organizes and supervises annual record retention review with team coordinator for destruction of applicable UI paper documents.

Skills on Resume:

• Claims Management (Hard Skills)
• Regulatory Compliance (Hard Skills)
• Liaison Expertise (Soft Skills)
• Data Analysis (Hard Skills)
• Appeals Process Handling (Hard Skills)
• Training and Development (Soft Skills)
• Interpersonal Communication (Soft Skills)
• Document Management (Hard Skills)

Job Summary: 

• Prioritize voluminous claim review workload.
• Validate claim status, claim liability and availability of coverage.
• Understand concepts of coverage, contract interpretation and reimbursement methodologies needed to analyze claims.
• Research and analyze information gathered through investigation
• Identify reimbursement issues, develop solutions and initiate appropriate claim resolution strategies.
• Maintain quality and productivity standards as set by Management.
• Influence others using a positive approach.
• Work independently with minimal supervision.
• Ensure compliance with Health Insurance Portability and Accountability Act.
• Works with UI vendor to file responses and protest after a complete and thorough investigation of all applicable facts

Skills on Resume:

• Workload Prioritization (Hard Skills)
• Claim Validation (Hard Skills)
• Contract Interpretation (Hard Skills)
• Investigative Research (Hard Skills)
• Problem Resolution (Soft Skills)
• Quality Maintenance (Hard Skills)
• Positive Influence (Soft Skills)
• Independent Work (Soft Skills)

Job Summary: 

• Research new and existing class action settlements
• Develop and execute project plan for assigned cases
• Oversee marketing and communication activities for assigned cases
• File claims on behalf of clients with claims administrator.  
• Work with clients and claims administrator to maximize recovery
• Update systems with pertinent updates from research and claims filing activities
• Develop case level valuation model to estimate anticipated recovery
• Regular communications with clients, sales organization, and client services about the particulars of assigned cases and case updates
• Actively participate in suggesting, testing, and implementing infrastructure changes and process improvements
• Processing non phone functions which may include research of payment, billing, account balance questions, responding 

Skills on Resume:

• Class Action Research (Hard Skills)
• Project Management (Hard Skills)
• Marketing and Communications Oversight (Soft Skills)
• Claims Filing (Hard Skills)
• Client Collaboration (Soft Skills)
• System Updates (Hard Skills)
• Financial Modeling (Hard Skills)
• Process Improvement (Soft Skills)

Job Summary: 

• Handle initial notification of new death claims and deceased owners through policy research
• Correspond through email to other business areas or units to inform about the death of a mutual client or locate mutual client's other policies
• Correspond with beneficiaries, lawyers, advisors and executors with unidentified policy numbers for clarification
• Real time monitoring of death claim inbox to ensure notifications are assigned prior market cut off time or day 0 work
• Participate in process discoveries and propose ideas for process improvement initiatives
• Deliver high quality claim handling and customer service consistent with the internal claim handling guidelines.
• Collaborate on the development and maintenance of Standard Operating Procedures, system and tool enhancements, and testing/piloting changes.
• Gain and apply a complete knowledge of claim line of business and regulatory needs.
• Ensure accurate and timely claim setup, assign new claims to claim handler 
• Properly identify and handle claim documents.

Skills on Resume:

• Policy Research (Hard Skills)
• Business Communication (Hard Skills)
• Real-Time Monitoring (Hard Skills)
• Process Improvement (Soft Skills)
• Claim Handling (Hard Skills)
• Collaborative Development (Soft Skills)
• Regulatory Knowledge (Hard Skills)
• Document Management (Hard Skills)

Job Summary: 

• Manage claim-related responsibilities for assigned clients
• Accurate and timely adjudication of claims inclusive of all required notations Research, resolve and respond 
• Claim appeals and inquiries to include the organization, sorting and entry of details
• Maintain department productivity, quality and turn-around-time standards
• Preparation of required payment initiation and related correspondence.
• Build and maintain proactive and positive working relationships with clients and brokers.
• Engagement in projects and process improvement initiatives, as requested by leadership.
• Process financials and handle bordereau analysis and reconciliation when applicable.
• Extensive communication /coordination with other disciplines.
• Analysis and appropriate action of medical documents, correspondence and notices received within the Claims team.

Skills on Resume:

• Claim Adjudication (Hard Skills)
• Data Entry (Hard Skills)
• Financial Reconciliation (Hard Skills)
• Document Analysis (Hard Skills)
• Quality Standards (Hard Skills)
• Relationship Management (Soft Skills)
• Process Improvement (Soft Skills)
• Team Coordination (Soft Skills)

Job Summary: 

• Partners with the MCIC Claims team members to set the strategic direction for project/initiative and will collaborate through all aspects of the project lifecycle
• Assisting in project planning, analysis, development, change control, and deployment
• Defines, maintains and applies project management tools and frameworks (i.e., methodology, process, and templates)
• Monitors projects to ensure prioritization and timeliness in order to meet the defined strategic goals and objectives
• Develops and maintains detailed project plans using standard tools 
• Defines project concept, charter, scope, tasks, assignments, dependencies, and target dates
• Collaborates with MCIC Claims team members to determine and secure needed resources for each project. 
• Acts as an advisor to project teams on how to best prepare, package, and message deliverables to ensure adoption and deployment
• Assists in the preparation and monitoring of project/Initiative budgets
• Emails, written correspondence, order processing, and account maintenance 

Skills on Resume:

• Project Management Tools Proficiency (Hard Skills)
• Project Planning and Scheduling (Hard Skills)
• Resource Management (Hard Skills)
• Project Monitoring and Control (Hard Skills)
• Budget Management (Hard Skills)
• Stakeholder Communication (Hard Skills)
• Change Management (Hard Skills)
• Documentation and Reporting (Hard Skills)

Job Summary: 

• Analyze and adjust litigated and non-litigated legal matters with minimal supervision 
• Monitor, evaluate, and document claims and incidents 
• Recommend authority to managers based upon evaluation and judgment 
• Participate independently in mediations with delegated authority limits 
• Interact with members and counsel on matters of judgment and discretion 
• Develop and maintain relationships with members, brokers, and counsel 
• Responding to inquiries from members, pharmacies, and/ or providers related to benefits, eligibility, customer material requests, physician look-up, authorization, explanation of benefits (EOB), caller information, status checks, and other related information.
• Process Health Insurance claims.
• Make outbound calls and transfers as per the Standard Operating Procedures (SOPs).
• Work on special projects and/or non-phone work to complete as directed.

Skills on Resume:

• Legal Analysis (Hard Skills)
• Claims Monitoring (Hard Skills)
• Decision Making (Soft Skills)
• Mediation Participation (Hard Skills)
• Relationship Management (Soft Skills)
• Inquiry Response (Soft Skills)
• Claims Processing (Hard Skills)
• Project Management (Soft Skills)

Job Summary: 

• Works complicated reports, which involves critical decision making on adjustments, overrides of copayments, coinsurance, correct pricing and provider selection
• Perform side by side comparisons to determine corrected claim actions
• Issues form letters & forms, when appropriate
• Performs initial overpayment recoupment process in the overpayment application
• Understands complicated pricing calculations for medical and hospital claims processing
• Process Professional and Hospital claims accurately and timely within claiming system
• Process claims according to set guidelines for payment or denial
• Price claims according to Medicare, Medicaid and custom fee schedules
• Meet personal and team goals and metrics
• Ordering investigative reports, medical, financial and other records 

Skills on Resume:

• Complex Reporting (Hard Skills)
• Comparative Analysis (Hard Skills)
• Documentation Management (Hard Skills)
• Overpayment Recoupment (Hard Skills)
• Pricing Calculations (Hard Skills)
• Claims Processing (Hard Skills)
• Guideline Adherence (Soft Skills)
• Investigative Reporting (Hard Skills)

Job Summary: 

• Make outbound calls to obtain additional information required to process claims
• Handles challenging situations and acts with appropriate level of urgency
• Processes claims through timely and accurate entry of data
• Follow precise instructions to process claims
• Completes assigned work and maintains production and quality metrics
• Follow changing instructions
• Interact with other departments in resolving issues
• Investigate and respond to complex issues for successful resolution of claims
• Research and resolve adjustment inquiries
• Performs edit resolutions from pended paper and electronic claims using critical decision-making skills for accurate claims processing

Skills on Resume:

• Data Entry (Hard Skills)
• Claims Processing (Hard Skills)
• Issue Investigation (Hard Skills)
• Edit Resolution (Hard Skills)
• Outbound Communication (Soft Skills)
• Handling Urgency (Soft Skills)
• Interdepartmental Interaction (Soft Skills)
• Critical Decision-Making (Soft Skills)

Job Summary: 

• Initializing all claims for disability and health and assign claim number
• Paying ongoing /continuance claims within authority level
• Referring continuance claims after 3 months of benefits have been paid to higher level
• Processing continuance claims when referred back from higher level
• Making judgments within the standards of completeness, timeliness and accuracy regarding payment, denial or investigation
• Reading and analyzing medical records
• Auditing claims within a dollar limit
• Understanding and applying policy provisions
• Composing and typing correspondence to policy holders, doctors, employers 
• Calling claimants and/or employers for additional information

Skills on Resume:

• Claims Processing (Hard Skills)
• Decision Making (Soft Skills)
• Medical Records Analysis (Hard Skills)
• Auditing (Hard Skills)
• Policy Application (Hard Skills)
• Communication (Soft Skills)
• Authority Level Adherence (Soft Skills)
• Information Gathering (Soft Skills)

Job Summary: 

• Interprets and applies law to administer workers' compensation claims in compliance with all rules, regulations and reporting requirements of the Labor Code, Division of Workers' Compensation, Self-Insurance Regulations, and other administrative laws. 
• Reviews and approves benefits payable to injured employee, invoices including attorney bills, medical provider bills, liens and mileage. 
• Rates employee's permanent disability. 
• Reviews and monitors employee medical records to ensure scope and duration of treatment are appropriate based on the injury and diagnosis. 
• Reports appropriate cases to excess insurance and seek reimbursement. 
• Manages litigated cases and non-litigated cases with complex issues. 
• Focuses on cost effective solutions and seeks recovery from third parties. 
• Communicate with supervisor on workload/issues/backlog
• Provide customer support for a 1-800 line inquiries 
• Manually enter data from CMS1500 and UB04 claims into claiming system 

Skills on Resume:

• Legal Compliance (Hard Skills)
• Benefits Administration (Hard Skills)
• Medical Records Review (Hard Skills)
• Data Entry (Hard Skills)
• Effective Communication (Soft Skills)
• Customer Support (Soft Skills)
• Problem Solving (Soft Skills)
• Workload Management (Soft Skills)

Job Summary: 

• Analyzes claims to ensure accuracy of the services and charges submitted. 
• Make judgment calls while adhering to program policies and procedures 
• Ensure accurate and prompt reimbursement for service provider expenses. 
• Understanding of the rate structures in place, for each program.
• Communicates proficiently with Clients regarding services and corresponding rates.
• Produces and analyzes a series of data reports required by clients.
• Assists the department program managers with customer and dealer reimbursements.
• Serves as the department's primary point of contact with managers regarding the reimbursement of service provider expenses. 
• Audits submissions in the System and provides instruction to clients on corrective action necessary to facilitate payment.
• Analyzes call detail on selected groups of service events
• Validate accuracy of data prior to reimbursement to clients, contacts clients when further clarification

Skills on Resume:

• Data Analysis (Hard Skills)
• Financial Acumen (Hard Skills)
• Policy Adherence (Soft Skills)
• Client Communication (Soft Skills)
• Problem Solving (Hard Skills)
• Auditing (Hard Skills)
• Customer Service (Soft Skills)
• Project Management (Soft Skills)