Job Summary:

• Handles personal Insurance claims issues.
• Investigate personal Insurance Coverage questions and problems.
• Monitors and reviews all new Insurance claims for designated clients and establishes a plan of action to achieve a favorable claim resolution.
• Reviews claim status and reserves in consideration of client costs.
• Works closely with clients, account executives, producers, managers, and insurance carriers.
• Create favorable relationships with clients and adjusters.
• Operates independently and can service demanding clients who expect prompt attention.
• Ensure that all assigned claims are resolved timely, reserved accurately and handled fairly. 
• Act as the primary point of contact to investigate and analyze the insurance company's liability concerning first party homeowner property losses and or damages.         
• Effectively communicate with policy-holders, agents and service providers to accurately document claim details.

Skills on Resume: 

• Claims Investigation and Analysis (Hard Skills)
• Claims Management (Hard Skills)
• Financial Acumen (Hard Skills)
• Client Relationship Management (Soft Skills)
• Communication (Soft Skills)
• Independence and Initiative (Soft Skills)
• Timeliness and Fairness in Claims Resolution (Soft Skills)
• Point of Contact (Soft Skills)

Job Summary:

• Manage the claim activities for the assigned region by organizing and coordinating efforts of per diem adjusters to timely settle numerous claims.
• Stay abreast of all crop insurance industry procedures relating to proper administration of claim settlement procedures.
• Answer inquiries from agents, adjusters, and insureds pertaining to the interpretation of policy provisions and FCIC guidelines as apply to MPCI claims.
• Assign crop insurance adjusters to work crop claims.
• Train crop insurance adjusters on incorrect loss adjustment procedures and compilation of necessary paperwork.
• Assist in training agents about responsibilities relating to answering questions from insureds involving claims procedures.
• Assist in gathering Quality Control required reviews.
• Ability to handle upwards of 50 claims per month at varying stages in the claims process.
• Evaluate and apply the insurance policy as it pertains to making payments and declination of claims.
• Ability to understand, computer generated loss estimates and construction terminology.
• Create and maintain comprehensive claim handling notation in electronic claims management system and other related applications.

Skills on Resume: 

• Claims Management (Hard Skills)
• Industry Knowledge (Hard Skills)
• Policy Interpretation (Hard Skills)
• Adjuster Coordination (Soft Skills)
• Training and Development (Soft Skills)
• Quality Control (Hard Skills)
• Claims Processing (Hard Skills)
• Documentation and Reporting (Hard Skills)

Job Summary:

• Work directly with assigned providers in the company's Provider Network regarding moderate to more complex billing, payments, and other issues presented.
• Research and resolution of unpaid, pended, unprocessed, and denied claims..
• Identifies trends that impact the provider denials and pended claims.
• Reprocess claims for prior authorizations, extended billing days, retroactive Medicaid, etc.
• Provides customer service via telephone as well as written to assigned providers.
• Assists providers regarding claims, payments, denials, and remittance advice.
• Maintains a working knowledge of the claims software to include eligibility, utilization management, claims adjudication edits, and reimbursement rates.
• Participates in quarterly file reviews and claims audits.
• Participate, as needed, in trials, arbitrations, and mediations.
• Advise Division, TPA, Law Department, and carriers on claims issues and resolution strategies, provide settlement authority and while assuring the application of coverage and policy provisions.
• Responsible for insured claim recovery activity.
• Conduct initial coverage review, identify, negotiate and resolve potential issues with Risk, TPA, and coverage counsel.

Skills on Resume: 

• Claims Processing Expertise (Hard Skills)
• Trend Identification (Hard Skills)
• Claims Reprocessing (Hard Skills)
• Customer Service (Soft Skills)
• Claims Software Proficiency (Hard Skills)
• Auditing and Compliance (Hard Skills)
• Legal and Settlement Support (Hard Skills)
• Risk Management and Negotiation (Hard Skills)

Job Summary:

• Provide direction, and guidance to internal claims staff, a third-party administrator (“TPA”), and legal counsel on claims and coverage issues.
• Interact with the Risk Management staff and the TPA on coverage matters claims resolution strategies and settlement.
• Authorize the settlement of claims within settlement authority.
• Participates in training Area and Division staff, whether in person or by webinar, in claims reporting and claims administration.
• Participate in the completion of various Risk Department projects as assigned.
• Participate in meetings and provides reporting as required.
• Understand and explain complex insurance issues.
• Negotiate and strategize the resolution of claims.
• Communicate effectively with internal and external customers (Senior, Area and Division management, auditors, insurance brokers, insurance carriers, and subcontractors).
• Work independently, set goals, and achieve results.
• Meet deadlines, prioritize, react quickly, and handle highly charged situations.

Skills on Resume: 

• Leadership and Direction Setting (Hard Skills)
• Claims Management Expertise (Hard Skills)
• Training and Development (Hard Skills)
• Project Management (Hard Skills)
• Effective Communication (Soft Skills)
• Negotiation Skills (Hard Skills)
• Independence and Goal Orientation (Soft Skills)
• Crisis Management and Decision Making (Hard Skills)

Job Summary:

• Responsible for the review and adjudication of services flagged by claims editing software within the claims transactional system, according to plan benefits, contractual reimbursement terms, and industry standards
• Responsible for review and resolution of provider correspondence related to claim denials generated by claims editing software
• Responsible for review and resolution of customer service issues related to claims reimbursement edits
• Responsible for analysis and recommendations to increase the automation of claims edits
• Responsible for identification and review of repetitive and/or inaccurate billing practices on a claim submission and/or content level
• Responsible for identification and review of potential overpayments of claims
• Responsible for determining if correct billing/coding requirements have been met including service to diagnosis compatibility, patient and provider demographic compatibility, revenue-to-service code compatibility, claim form field data validity
• Responsible for outreach to providers to promote provider education via written and verbal correspondence
• Responsible for recommendations for areas of provider claim submission and/or billing and reimbursement education
• Responsible for triage of potentially fraudulent or abusive billing patterns to the Claims Auditing Unit
• Responsible for triage of configuration issues
• Develop and maintain cumulative reports and spreadsheet

Skills on Resume: 

• Claims Processing Expertise (Hard Skills)
• Provider Correspondence Management (Hard Skills)
• Customer Issue Resolution (Hard Skills)
• Automation and Process Improvement (Hard Skills)
• Billing Practices Analysis (Hard Skills)
• Overpayment Identification (Hard Skills)
• Billing/Coding Compliance (Hard Skills)
• Provider Education and Outreach (Soft Skills)