• Review and assess inventory levels coordinating daily allocations and planning to maximize staffing levels to maximize results
• Ensure that productivity, quality and customer satisfaction, are managed within the own team and motivation of the individuals and team to achieve the operational KPIs
• Monitor inventories and customer feedback to anticipate potential problems
• Bring creative solutions to address the short-term need, understanding and implementing improvements for the future
• Actively develop team members by ensuring suitable training and development plans are in place and conducting training analysis 
• Conduct regular staff check-ins, ensuring goals are in place and monitored, performance is reviewed and recognized and career development discussed
• Engage, motivate and inspire individuals by keeping focus on employee engagement
• Develop effective relationships and communications with internal and external customers to ensure a highly engaged seamless delivery of service.
• Actively encourage all team members to do likewise
• Create a positive and motivated environment for the team, engaged in delivering for the customers
• Support projects and initiatives by being proactive in seeking new ideas and ensuring the customers’ requirements are accounted for while delivering efficient operational change
• Produce meaningful, accurate management reports and statistical information

Skills: Inventory Management, Team Leadership and Motivation, Problem Anticipation and Solution Implementation, Training and Development, Performance Management, Employee Engagement, Customer Relationship Management, Project Support and Reportin

• Monitors the turn-around time and quality for the claims processing teams and assures resources are re-prioritized (or re-trained) to meet the existing service level agreements with clients.
• Develops, implements and coordinates programs/training to improve efficiency and performance.
• Provide input into the prioritization of projects within the company.
• Handles escalated carrier inquiries other department inquiries and complex claim issues.
• Responsible for direct reports including the Claims Supervisors.
• Provide ongoing coaching and development opportunities to direct and indirect reports.
• Provide support training to onboard new Operational team members (ad-hoc classes on claims or claims activities and not FTE training requirement).
• Identifies system workflow requirements to enhance team efficiency.
• Releases high-dollar claims and researches the cause of discrepancies and makes recommendations.
• Direct claim employees on proper claim reserving and payments
• Ensure competent investigating and negotiating skills to achieve proper claim settlements

Skills: Leadership and Team Management, Claims Processing Expertise, Quality Assurance and Monitoring, Training and Development, Project Prioritization and Management, Workflow Optimization, Problem Solving and Decision Making, Communication and Interpersonal Skills

• Facilitates a work environment that fosters and supports ethical decision-making and actions by motivating, promoting and modeling ethical behavior
• Executing job responsibilities following Citizen’s core values, ethics and information protection policies
• Responsible for managing claim personnel including hiring, training, performance assessment, planning and delegation of workload
• Coach and motivate to improve the quality and quantity of work performed.
• Conducts audits of the claims process to include coverage analysis, investigation, valuation, scope, estimate, reserving and the accurate disposition of claims.
• Completes field re-inspections of vendor or employee claims to ensure proper claim handling and compliance with company procedures.
• Communicates with agents, policyholders, Claim Unit personnel, and External and Internal Stakeholders.
• Manage and adjust claims by Citizens Best Claims Practices and Estimating Guidelines including proficiency with the electronic estimating system and management applications.
• Develops, analyzes and reports metrics useful in measuring team performance as well as effectiveness of the claim’s operations.
• Participates in training and/or mentoring of internal, external and/or contracted staff.
• Participates in workload surges and/or catastrophe response including mandated overtime during specific catastrophic events.
• Achieve satisfactory productivity levels through managing claim loads and identifying specific training needs
• Manage employee performance to achieve unit, department, and company goals

Skills: Ethical Leadership, Team Management, Coaching and Motivation, Audit and Compliance, Communication Skills, Claims Handling, Metrics Analysis, Training and Development

• Manage supervisors, monitor team performance, and monitor operational deliverables for the team.
• Manage relationships between stateside counterparts for the smooth performance of the team and to achieve company-wide goals.
• Monitor workload fluctuations and adjust staff assignments accordingly both directly and by coaching supervisors.
• Responsible for management and oversight of the Claims/Enrolment Department to ensure timely adjudication of claims/updating members' records for health care services, received from contracted and non-contracted providers
• Ensure all Federal, State and Client requirements are met timely and efficiently by regulations and client guidelines.
• Manages a multi-functional unit of claim professionals/Enrollment associates and support staff.
• Leads claim/Enrollment team in support of department initiatives and strategies in cost containment, case file handling, customer service and quality.
• Consistently monitors workflows to maximize accuracy and efficiency.
• Maintains an acceptable level of service and customer satisfaction and retention.
• Effectively manages the quality review process.
• Develops unit goals, objectives, processes, procedures and systems.
• Stays abreast of changes in health plan benefits and pricing methodologies.

Skills: Team Management, Operational Oversight, Relationship Management, Compliance and Regulations, Process Improvement, Quality Assurance, Strategic Leadership, Adaptability and Problem-Solving

• Managerial oversight of 4 – 6 direct report claims adjusters
• Maintain a managerial diary and ensure claims are handled in compliance with company best practices
• Assure the proper and timely disposition of claims that can be settled within the team's authority
• Oversee the appropriate distribution and assignment of claims within the team to ensure customers/claimants are having their matters addressed within company and legal timeframes
• Responsible for ensuring claim quality and the desired outcome is achieved through consistent oversight of litigated claims.
• Authorize settlements that exceed direct reports limits but within personal authority limits
• Participate in recruiting, hiring, and training programs to support the staffing needs of the organization
• Conduct quality assurance and performance management reviews
• Collaborate with management team in ongoing process and performance improvement planning and in QA calibration sessions
• Communicate effectively, plan/organize work, analyze/solve problems, and focus on the larger picture.
• Identifies team staffing needs and takes necessary measures to ensure appropriate levels of service.
• Mentors employees and develops career paths with growth opportunities.
• Participates in the development of annual departmental budget, monitors budget and identifies budget discrepancies.

Skills: Managerial Oversight, Claims Management, Settlement Authorization, Recruitment and Training, Quality Assurance, Process Improvement, Communication and Problem Solving, Budget Management

• Demonstrates a commitment to communicating, improving and adhering to safety policies in all work environments and areas.
• Main point of contact for Casualty claims. 
• Act as the liaison between internal employees and third-party adjusters.
• Provide and implement recommendations for improvements to the claims process.
• Maintain accurate records of claims and claim-related activities.
• Management of a team of Workers' Compensation adjusters, with some responsibilities involving Auto Liability and General Liability Adjusters.
• Participate in Quarterly claims calls and regular meetings with HR, Safety and Business Units.
• Prepare reports, including reserves, settlements, WC State compliance, file audits and other ad hoc reports
• Review and process payments of claims and related expenses.
• Respond to urgent situations or rush requests for information and advice.
• Attend mediations, hearings and trials and facilitate periodic project tracking to management 
• Validate and ensure department compliance with company requirements
• Participates in special projects and serves on committees

Skills: Safety Adherence and Improvement, Claims Management, Liaison and Communication, Process Improvement, Record Keeping, Team Leadership, Reporting and Analysis, Compliance and Validation

• Responsible for handling a unit of mid-level, experienced examiners, capable of handling both Property Damage and Bodily Injury with reportable exposures valued at 50K or higher
• Lower-level litigation and coverage cases may emerge or exist from the inventory load of the unit.
• Claims of this nature would be expected to be handled within the group
• Plans, schedules and supervises the work activities of the unit's personnel in reviewing, analyzing, investigating, negotiating and settling claims in compliance with established standards and expectations
• Reviews claim loss reports, assesses the complexity of submitted claims and assures claims are assigned to appropriate personnel (based on licensure, knowledge, skills and abilities) to ensure optimal claims handling within the team
• Serves as a technical resource for staff
• Reviews and approves, within assigned authority limits, claim expenses and settlements that exceed the claim adjusters granted authority
• Appropriately refers claim expenses and settlements that exceed personal authority limits for approval
• Handle multiple coverage lines with a specific concentration on mid-level exposure Auto and GL involving varying program segments
• Interpret coverage, provide guidance on coverage matters and review reservation of rights and disclaimers for carrier approval.
• Monitors and evaluates reserves for claims within the unit to ensure that they are adequate and that reserve adjustments are made, consistent with established time frames
• Manage compliance requirements with claim handling guidelines and ensure good faith claim handling

Skills: Claims Handling Expertise, Supervisory and Leadership Skills, Technical Resource, Financial Management, Coverage Interpretation, Reserve Management, Compliance Oversight, Team Collaboration and Training

• Conducts regular reviews of pending and closed files to determine whether claims are handled appropriately
• Identifies areas for improvement and discusses individual training and development needs 
• Prepares monthly reports on quality control, pending and closed file reviews and reserve activity
• Track and communicate unit performance relating to production, opportunity areas and significant achievements
• Maintains awareness of existing and proposed legislation, court decisions and emerging trends in claims litigation M
• Monitor the company's compliance with the Unfair Claims Practices Act and recommend process and/or procedure changes
• May participate in special projects such as analyzing reserves, leakage, methods for pending reduction and acquisition candidates
• Review and approve direct report monthly expense reports and related operating expenses for their assigned unit.
• Works closely with all levels of management to ensure compliance with budget targets for compensation, expense control and profitability.
• Assists in the selection of and monitors the performance of external vendors.
• Works closely with the Senior Claims Examiners and claims management team to identify the needs of the unit 
• Assist with hiring, training, motivating and retaining staff, evaluating staff performance
• Encourage staff development, recommending salary actions
• Develop performance improvement plans and recommend individual terminations of employment.

Skills: Claims Handling Expertise, Quality Control and Reporting, Performance Tracking and Communication, Legislative Compliance, Process Improvement, Project Management, Financial Oversight, Team Leadership and Development

• Responsible for supervising the overall quality of claims processes as they pertain to departmental policies and procedures as well as compliance, with CMS, DMHC, and Health Plan and contractual obligations
• Responsible for coordinating subordinate employee recruitment, performance assessment, work assignments, salary, and recognition/disciplinary actions.
• Provide training support for new employees and existing Claims Examiners.
• Distributes work through review of inventory and pending claim reports.
• Provide claims support to teams in reviewing, and resolving, member and provider appeals and disputes.
• Responsible for processing and responding to Health Plan inquiries and coordinating with appropriate departments for any provider, member, or system issues.
• Responsible for recommending changes in guidelines, procedures, and policies.
• Ensuring the use of standard methodology workflows and operational excellence.
• Advise the training of team members on workflow and contractual modifications expeditiously.
• Supervising, scheduling, assigning, monitoring and evaluating work of assigned staff are responsibilities for supervisor positions.
• Provide direct supervision to examiners, adjusters, claims assistants and all liability claims staff
• Review and approve direct report monthly expense reports and related operating expenses for their assigned unit.
• Works with clients to address issues regarding policies, programs and/or claims

Skills: Leadership and Supervision, Training and Development, Policy and Procedure Management, Claims Process Oversight, Workflow Optimization, Conflict Resolution, Communication and Coordination, Performance Monitoring and Evaluation

• Safeguards and preserves the confidentiality of patient's protected health information by State and Federal (HIPAA) regulatory requirements, and hospital and departmental policies.
• Ensures a safe patient environment and adherence to safety practices per policy.
• Resolve biophysical, psychological, educational and environmental needs of patient/significant other when administering care.
• Support the strategic direction of community benefits within clients and its affiliates.
• Disributes day-to-day work assignments, and prioritizes work for the examiners.
• Review claims for Professional & Institutional Providers to guide the staff.
• Coordinates research provider data and adjudication issues and ensures communication of required system updates to Provider Contracting and Claims Operations.
• Acts as the liaison between examiners, business configuration and business owners to ensure that all application and technical-oriented issues relating to the configuration requests/projects are appropriately addressed
• Assists in establishing, and documenting policies and procedures in support of claims adjudication.
• Works with Management to achieve company initiatives and performance goals.

Skills: HIPAA Compliance, Patient Safety and Environment, Patient Care and Support, Community Benefits Strategy, Work Prioritization and Assignment, Claims Review and Guidance, Coordination and Communication, Policy and Procedure Development

• Intermediate to Advanced Microsoft Office Suite (Word, Excel, Access,)
• Leadership skills and ability to adapt to change, work independently
• Strong verbal and written communication skills
• Ability to relate to people from diverse backgrounds
• Ability to organize projects and manage multiple priorities
• Attention to detail and having Claims experience 
• Familiarity with HIPAA-compliant health-related electronic file transactions 
• Have a thorough knowledge of and appreciation for, the regulatory and political environment. 
• Be able to multi-task and prioritize effectively to meet deadlines 

Qualifications: BA in Business Administration with 4 years of Experience

• Experience Microsoft Excel, Word, Outlook, Access, SharePoint
• Have managing/supervising experience
• Knowledge of adjudication systems and platforms
• Effective leadership skills and ability to discern behavioral trends and outcomes
• Well-organized with the ability to effectively prioritize work
• Attention to detail and ability to think of creative solutions
• Flexible in adapting to changes
• Skilled in identifying and solving issues to conclusion
• Ability to work effectively cross-functionally
• Excellent written and oral communication

Qualifications: BA in Healthcare Administration with 3 years of Experience

• Prior workers’ compensation leadership experience
• Multi-state workers’ compensation claims experience
• Strong technical knowledge of claims investigation techniques, compensability, and insurance coverage
• Negotiation skills and ability to stay current on statutes for assigned states
• Ability to obtain and maintain licensing and state certification
• Demonstrated commitment of outstanding claims service and account management to internal and external customers
• Excellent communication, organization, planning and prioritization skills
• High leadership and Analytical Skills
• Demonstrate ability to document and present concepts in a clear and concise manner
• Effective use of all Windows-based applications such as Word, Excel and PowerPoint

Qualifications: BA in Insurance and Risk Management with 5 years of Experience

• CPC (Certified Professional Coding) certification, or equivalent business experience
• Prior experience with self-funded plans and/or in Taft-Hartley or collective bargaining environment
• Advanced degree or certifications (e.g., CEBS, etc.)
• Have a solid knowledge of claims administration (both electronic and paper claims processing), health and welfare benefits 
• Knowledge of governmental/legislative regulations governing such plans. 
• ICD-10 understanding and medical terminology certification
• Dental claim processing experience
• Knowledge of Basys (system vendor) 
• Be a professional with demonstrated leadership skills
• Proven “hands-on” supervisory style, excellent judgment, and a strong work ethic. 
• Possess exceptional interpersonal and communication skills
• Strong project management skills, strong analytical skills and be highly organized. 

Qualifications: BA in Finance with 4 years of Experience

• Experience in supervising insurance claims billing and follow-up in an outpatient healthcare setting
• An approved combination of education and experience
• Excellent problem-solving & communication skills (verbal & written)
• Knowledge of EPIC claims processing systems and electronic health records
• Adaptable to changing priorities, tasks, and work schedules to meet department standards
• Knowledge of the quality improvement processes
• Skilled in overseeing the efforts of individuals within the department
• Ability to effectively involve department staff in the application of quality measurement and improvement tools
• Skilled in fostering a positive workplace culture and building inclusive workplace teams
• Demonstrated ability to quickly learn new technologies and systems and provide instruction on complex processes
• Capable of assisting managers with decisions and activities

Qualifications: BA in Economics with 5 years of Experience

• Ability to communicate effectively with both internal and external associates, written and oral techniques
• Ability to look at situations and barriers to creatively provide solutions that meet the needs of all parties in the best collective manner possible
• Proactive in identifying and implementing solutions
• Must genuinely intend to work cooperatively with others
• Embraces change and demonstrates a willingness to learn
• Ability to take simultaneous direction from multiple sources and manage conflicting priorities in an effective manner
• Thorough understanding of laws, principles of coverage, liability and the insurance industry in general.
• Analytical and human relations skills are critical.
• Strong leadership skills and ability to plan, organize, delegate, and develop corporate human resources.
• Ability to appropriately prioritize and carry out work
• Ability to comfortably and effectively facilitate meetings and feedback sessions

Qualifications: BA in Public Administration with 6 years of Experience

• Experience in an Auto Supervisory role for Personal Auto Claims
• Experience handling Casualty and/or Liability claims
• Exceptional organizational and time management skills
• Demonstrates computer proficiency, and excellent written and verbal communication skills
• Be willing to submit to a background investigation, any offer of employment is conditioned upon the successful completion of a background investigation
• Ability to obtain information from others and deliver information to others orally and in written form.
• Ability to carry out detailed written and verbal instructions.
• Ability to work with little supervision and direction.
• Sound command of the English language.
• Ability to operate business technology.

Qualifications: BA in Legal Studies with 3 years of Experience

• Proven leadership, coaching, and teamwork skills
• Excellent verbal and written communication skills, including a strong ability to actively lead or participate in meetings, presentations and conferences.
• Excellent customer service skills gained through previous work experience, with an emphasis on accessibility, listening and responsiveness.
• Computer literacy, including working knowledge of MS Office including Word, Excel and PowerPoint.
• Progressively responsible experience in handling Automobile, General Liability, Professional Liability and Property claims.
• Excellent customer service skills gained through previous work experience, with an emphasis on accessibility, listening and responsiveness.
• Computer literacy, including working knowledge of MS Office including Word, Excel and PowerPoint.
• Thorough knowledge of claims procedures including Litigation Management and Subrogation programs
• Effectively influence people to achieve unit and organizational objectives

Qualifications: BA in Human Resources Management with 7 years of Experience

• Previous supervisory experience and professional designation desired.
• Strong experience handling Worker's Compensation claims in multiple states
• Multi-line claims experience 
• Ability to communicate effectively orally and in writing with people at all levels of the organization
• Strong organizational skills, analytic and problem-solving skills
• Have property claims handling experience
• Have Property Supervisor/Management experience
• Excellent leadership and customer service skills
• Proficiency with current MS Office suite 
• Experience with benefits administration systems

Qualifications: BA in Communication Studies with 5 years of Experience

• Commercial Auto, Bodily Injury, Property Damage and General Liability experience 
• Trucking claims experience 
• In-depth understanding of company's operating structure
• Proficiency in determining case value and negotiating settlements
• Comprehensive knowledge of claims-handling systems
• Maintain confidentiality of information
• Thorough knowledge of coverage and claims investigation techniques.
• People management skills including interviewing skills, training, team building, and performance management
• Proficiency at applying business and technical acumen by understanding how the business works and how technology supports business initiatives.
• Handles stressful situations and deadline pressures well

Qualifications: BA in Psychology with 6 years of Experience