• Processes a Disability claim by reviewing the eligibility, diagnosis, services rendered, employer’s statement and medical records under the plan’s benefits, limitations and exclusions
• Process a Life claim by reviewing the Death certificate, eligibility, cause of death
• Request for payment form under the plan’s benefits, limitations and exclusions
• Update and distribute reporting for this area
• Handles all lines of business with a low to high level, depending on complexity and stage of training
• Demonstrates responsibility for investigating coverage issues and/or liability
• Ensures compliance with state regulations and requirements
• Focuses primarily on proper fact-finding, investigation and resolution of all claims of low-level complexity
• Br responsible for analyzing policy coverage, drafting coverage letters, managing, monitoring and resolving first-party losses. 
• Be an integral part of the in-house claims servicing team. 
• Interact directly and daily with the clients and business partners, so a passion for superior customer service and professionalism are key characteristics of the role.
• Be responsible for reviewing claim submissions and policy documents, obtaining pertinent documents in conjunction with claim submissions, resolving basic claims
• Act as the first point of contact for claim inquiries and questions. 

Skills: Claims Processing, Regulatory Compliance, Investigative Skills, Policy Analysis, Reporting Proficiency, Customer Service, Complexity Management, Effective Communication

• Relying on instructions and pre-established guidelines, the Claims Examiner is responsible for accomplishing the following as guided by others
• Review coverage claims and determine whether the matter is covered under the applicable policy.
• Investigate coverage issues.
• Draft action plans, including coverage recommendations, for the approval of Claims Managers.
• Establish and revise claim reserves based on claim developments and counsel liability assessments.
• Draft coverage determination letters, including reservation of rights and denial letters.
• Obtain updates from defense counsel and/or coverage counsel and/or the Insured
• Authorize settlements based on liability and other considerations after receiving approval from claims management.
• Review, approve, and reimburse the Insured for legal, expert/vendor invoices, and settlement.
• Conduct detailed bill reviews to ensure appropriate payment.
• Maintain a claim file by accurately documenting all communications and activities.
• Communicate with brokers or reinsured clients to obtain information necessary for processing claims.

Skills: Claims Review, Issue Investigation, Plan Drafting, Reserve Management, Letter Drafting, Settlement Authorization, Invoice Management, Stakeholder Communication

• Accurately evaluates and adjudicates complex claims promptly and according to set standards. 
• Regular claims include but are not limited to professional claims, Lab, DME, ambulance, and outpatient facility UB claims.
• Conduct a thorough review of claims to ensure that there is no missing or incomplete information
• Able to review and match authorization for the service.
• A Validates claims data, member data, and provider data against information from claims processing or business processing systems
• Assists in optimizing workflows, troubleshooting and problem solving to claims.
• Develop and maintain any/all necessary documentation for claims adjudication
• Identifies and resolves provider billing issues, including provider/vendor communication in writing.
• Ensures accurate interpretation of government laws, rules, and regulations, internal organization guidelines.
• Research, accesses and utilizes online reference for claim issues and resolution.
• Assists with the completion of claims audits conducted on TPA.
• Accepts and performs other duties as assigned, including frequent special projects.
• Process mail, faxes, denial letters, EOBs, and ADRs.

Skills: Claims Adjudication, Claims Review, Authorization Verification, Data Validation, Workflow Optimization, Billing Issue Resolution, Regulatory Compliance, Documentation Management

• Processes and adjusts uncomplicated professional and facility and Rx claims according to claims processing guidelines.
• Reviews all output reports to ensure accurate benefit and rider determinations Completes reports to ensure prompt payment of claims.
• Coordinates win-scanning of claims-related documents into members' MACESS folders.
• Identifies and reviews problems systematically or procedurally with the Supervisor for timely follow-up and correction.
• Analyzes and processes high dollar, complex claims, claims in litigation and early death claims
• Verifies that the cession claimed was properly ceded to RGA Re and was properly established on the RGA Re administration system. 
• Takes steps to resolve questions that arise from these claims.
• Identifies undesirable underwriting and/or claim adjudication practices that require a need to elevate the claim. 
• Refers claims to underwriting, medical and/or legal departments. 
• May escalate the issue to the department vice president.
• Processes retroceded claims, assures that recoverable on large, complex retroceded claims are paid to RGA on a timely basis.
• Identifies opportunities for investigation or application of “best practices” in client claim activities.
• Verifies daily claim register by scanning the register to ensure accruals are reasonable, required fields are completed and that the register is free of obvious errors. 
• Take ownership to identify and report issues to appropriate management staff for resolution and work actively with the SCAN team to improve the support to the Members and Providers.

Skills: Claims Processing, Report Review, Document Coordination, Complex Claims Handling, System Verification, Problem Resolution, Claims Escalation, Best Practices Implementation

• Assists in training of new or junior associates.
• Processes payment for approved claims via ACH, wire transfer, or check.
• Process routine and complex electronic and paper medical claims (HCFA 1500, UB04) within the claims system, by plan provisions
• Ensure correct data entry, correct provider coding information and appropriateness of reported services
• Maintain company production and quality standards
• Demonstrate a strong commitment to the mission and values of the organization
• Excellent attention to detail and time-management skills.
• Follow, and understand HIPAA regulations and authorize accrual vouchers
• Work professionally and confidentially with patient information.
• Meets with members of other departments to discuss specific claim details or general claims issues.
• Closely manages defense counsel, outside investigators and surveyors to ensure that loss adjustment expenses are appropriate.
• Contribute to team effort by accomplishing related results
• Actively support the achievement of SCAN’s Vision and Goals.

Skills: Claims Training, Payment Processing, Claims Adjudication, Data Accuracy, Quality Standards, HIPAA Compliance, Collaborative Teamwork, Expense Management

• May be designated as claims contact for key accounts and programs in which case the Examiner will perform various account or program management tasks
• Preparing for and attending claim reviews
• Analyzing claims data and meeting with members of other departments to discuss the account status
• Meeting with and making presentations to account or program representatives
• Maintains adjuster licenses in states
• May be called upon to perform other tasks and duties within the claims department as dictated by business needs.
• Evaluation of all types of homeowner property claims.
• Communicate with independent adjusters and other experts to gather information on claims.
• Negotiate and explain settlements with the insured and/or their representatives.
• Knowledge of multiple policy forms.
• Manage workload and provide management with reports for late reporting per established UAC guidelines.
• Answer incoming telephone calls from agents, contractors and insureds.
• Review and analyze written information.

Skills: Claim Reviews, Data Analysis, Presentation Skills, License Maintenance, Property Claims Evaluation, Settlement Negotiation, Policy Knowledge, Communication Skills

• Rely on training and guidance from management to plan and accomplish goals.
• Supports catastrophe operations as needed to include working significant overtime during designated CATs.
• Evaluate and authorize the disposition of complex claims.
• Obtain and analyze medical records and financial documents.
• Initiate and monitor medical reviews, independent medical examinations, surveillance, and financial reviews.
• Correspond with policyholders, attorneys, medical facilities, reinsurers, outside vendors, and the insured's employer
• Interact with and request formal written opinions from Law and Medical/Underwriting departments
• Make decisions on the evaluation of claims using judgment, experience, and collaboration with senior associates
• Assist with recoveries from reinsurance carriers.
• Work professionally and confidentially with patient information.
• Communicate suggestions for improvement and efficiencies to management

Skills: Claims Evaluation, CAT Support, Document Analysis, Medical Reviews, Stakeholder Correspondence, Department Collaboration, Decision Making, Process Improvement

• Review claims for coverage and determine whether matter covers under the applicable policy.
• Investigate coverage issues.
• Draft action plans, including coverage recommendations, for the approval of Claims Managers.
• Establish and revise claim reserves based on claim developments and counsel liability assessments.
• Draft coverage determination letters, including reservation of rights and denial letters.
• Obtain updates from defense counsel and/or coverage counsel and/or the Insured, as appropriate.
• Authorize settlements based on liability and other considerations after receiving approval from claims management.
• Review, approve and reimburse the Insured for legal, expert/vendor invoices, and settlement.
• Conduct detailed bill reviews to ensure appropriate payment.
• Maintain a claim file by accurately documenting all communications and activities.
• Communicate with brokers or reinsured clients to obtain information necessary for processing claims.
• Identify potential policies and coverages for incoming claims

Skills: Claims Review, Coverage Investigation, Action Planning, Reserve Management, Letter Drafting, Settlement Authorization, Bill Review, Claims Documentation

• Handle non-routine complex issues pertaining to claims complications and claims processes
• Escalating where necessary, to ensure application of pertinent policy and action calculation of claims rates. 
• Review claim reports of high complexity to ensure accurate records are produced and distributed. 
• Distribute new claim notifications and updates to the team in order to ensure information shared is consistent and clear. 
• Ensure incoming documentation from clients and underwriters, guidance and feedback to colleagues are filed to keep documentation organized. 
• Inspect receipt of documentation by mail or phone to ensure operational excellence 
• Maintain ongoing and professional communication with insurers, clients, and underwriters
• Ensure that client and insurer-related materials are cataloged, distributed, and readily available to the team. 
• Review high volume of claim information on appropriate claim application(s) 
• Ensure compliance with any local service standards to maintain accurate records for Claims Advisory. 
• Create standard templates for insurance claims forms and review templates for effectiveness to ensure support staff produces consistent deliverables. 
• Check claim files and ensures files with missing information are properly flagged and follow-up correspondence is sent to insured or other involved persons for missing or supplemental information. 
• Performing independent research to seek validation or clarification where necessary to add advantage to Claims Advisory and support claims analysts.

Skills: Complex Issue Handling, Claims Escalation, Report Review, Information Distribution, Documentation Management, Stakeholder Communication, Compliance Assurance, Research and Validation

• Coordinate benefits between multiple insurance plans
• Investigate other party liability data
• Ensure accuracy and compliance with health plan administration and governmental rules and regulations
• Communicate via telephone with internal and external customers
• Actively reach out to injured workers and/or policyholders to ensure the key activities under the WICA 2019 are met. 
• Manage medical appointment for injured work workers where necessary
• Engage policyholders and/or business partners to ensure injury claims will be processed in a timely manner.
• Follow up with medical facilities for medical reports.
• Proper and timely filing of documents, reports, communication and file notes for all claims under the new WICA 2019 regime.
• Verify MOM claims daily reports and conducts reconciliation for claims.
• Manage incoming mails and e-mails through the general Claims e-mail box.
• Manage work injury claims including computation of payable benefits under the WICA Act (Out-patient MC days under 28 days), including timely reserving.

Skills: Benefits Coordination, Liability Investigation, Regulatory Compliance, Customer Communication, Claims Management, Medical Coordination, Document Filing, Claims Reconciliation

• Have claims processing experience
• Knowledge of ADA, CPT, HCPCS coding
• Basic knowledge of insurance terminology
• Working knowledge of ISO policies
• Computer savvy and strong attention to detail
• Microsoft Office/Suite proficient (Excel, Outlook, Word)
• Great interpersonal skills and highly organized
• Excellent communication skills (written and verbal)
• Flexible with moving from project to project while keeping track of progress
• Solid analytical, mathematical, and research skills

Qualifications: BS in Finance with 2 years of Experience

• Excellent organizational skills- flexible with moving from project to project while keeping track of progress
• Professional attitude, enthusiastic, reliable, and a team player.
• Effective written and verbal communication skills
• Basic Excel, Word, and Outlook skills
• Great interpersonal communication and ability to consistently meet deadlines
• A high-quality internet connection working remotely
• Have experience within LTC Claims.
• Knowledge of LTC contract language.
• Sound administrative and organizational skills.
• Have healthcare background

Qualifications: BS in Business Administration with 4 years of Experience

• Have medical claim processing experience
• Knowledge of coding and ability to work remotely
• Flexible work schedule
• Strong project management skills and ability to work independently
• Excellent human relations and customer service skills
• Experience with automated claims handling systems (paperless environment)
• Experience at an independent adjusting company
• Ability to be trustworthy, dependable, and team-oriented for fellow employees and the organization
• Ability to attend in-person file reviews in Orange County (based on current quarantine status)
• Excellent organizational skills and ability to multi-task
• Ability to type quickly, accurately and for prolonged periods

Qualifications: BS in Accounting with 3 years of Experience

• Claims Assistant experience supporting a Workers’ Compensation Examiner or Team 
• Medical Only Adjuster designation 
• Continuing hours must be current
• Completion of IEA or equivalent courses
• Administrators Certificate from Self-Insurance Plans 
• Experienced Indemnity Claims Adjuster Designation 
• Knowledge of workers' compensation laws, policies and procedures
• Understanding of medical and legal terminology
• Well-developed verbal and written communication skills with strong attention to detail
• Proficient in Microsoft Office Suite and ability to learn additional computer programs
• Reasoning ability, including problem-solving and analytical skills
• Proven ability to research and analyze facts, identify issues and make appropriate recommendations and solutions for resolution

Qualifications: BS in Economics with 5 years of Experience

• S.I.P. certification is required within one 1 year of hire.
• Have worker's compensation claims experience.
• Knowledge of the States Worker's Compensation system principles, statutes and judicial protocol (benefit calculation, compensability decision timeline factors, subrosa).
• Knowledge of OSHA and state reporting requirements.
• Ability to organize, prioritize, and complete multiple objectives.
• Excellent oral and written communication skills.
• Proficient reading skills and results-oriented can be counted on to exceed goals successfully.
• Strong interpersonal, negotiation, and customer service skills.
• Strong educational background
• Exposure to complex & litigated claims essential

Qualifications: BS in Risk Management and Insurance with 2 years of Experience

• Excellent knowledge of policies and coverage within this business line
• Knowledge of complex property damage & liability within transportation claims
• Knowledge of other areas of auto benefit (personal auto, trucking, auto injury, etc)
• Ability to manage key relationships with Attorneys, customers and other insurers
• Healthcare industry experience or equivalent
• Solid working knowledge of CPT, ICD-10, HCPCS coding guidelines and medical terminology preferred.
• Demonstrated ability to enter and process medium complexity claims efficiently and in a quality manner.
• Solid working knowledge of claim processing from all perspectives (submissions, processing, dependencies)
• MS Office and general PC skills.
• Can solve medium complexity problems with effective solutions.
• Analytical ability, gathers relevant information systematically.

Qualifications: BS in Health Administration with 6 years of Experience

• Strong computer skills and ability to multitask
• Able to work under strict deadlines
• Demonstrate initiative and handle tasks without constant supervision
• Good written and oral communication skills
• Prior health insurance background preferred
• Effective presentation skills, detail-oriented, excellent follow up
• Excellent verbal and written communication skills
• Must be able to participate in meetings with all levels of management within the organization
• Ability to multi-task in a fast-paced environment
• Must be service-oriented, quick learner, and team player
• Appreciation of cultural diversity and sensitivity toward the target population

Qualifications: BS in Criminal Justice with 8 years of Experience

• Excellent verbal and written communication
• Prioritize tasks appropriately and maintain organization
• Advanced critical thinking and problem-solving skills
• Strong decision-making ability and sound judgment
• Build client relationships
• Self-starter and self-disciplined in accomplishing tasks
• Willingness to obtain an Insurance Adjuster License
• Opportunities to volunteer and give back to local communities.
• Knowledge of multiple policy forms
• Understanding of estimating software

Qualifications: BA in Legal Studies with 3 years of Experience

• Equivalent combination of education and/or experience
• Must be able to take direction from leadership and be detail-orientated.
• Must be very organized and able to multi-task.
• Must be able to make timely commitments and follow through on commitments made.
• Must possess strong investigative skills with the ability to achieve optimal conflict resolutions.
• Must be able to work in a fast-paced environment and possess excellent time management skills.
• Must possess excellent written and verbal communication skills.
• Must be proficient with MS Office.
• Competitive starting salary commensurate with experience.
• Potential bonus pay based on company performance.

Qualifications: BS in Statistics with 5 years of Experience

• Experience in a claims-examining role
• Experience in dental office or claims adjudication knowledge is preferred.
• PC literacy required, MS Office skills (Outlook, Word, Excel and PowerPoint.).
• Analytical, problem-solving and reasoning skills and detail orientation.
• Ability to organize time management and multi-tasking abilities.
• Ability to work under pressure and meet deadlines.
• Ability to follow verbal and written instructions.
• Ability to effectively communicate problems, questions and explanations.
• Knowledge of Delta Dental systems or organization and knowledge of healthcare industry issues

Qualifications: BS in Actuarial Science with 7 years of Experience