Claim processor jobs in Canton, OH - 26 jobs

SummaCare - 1200 E Market St, Akron, OH Full-Time / 40 Hours / Days * Hybrid after training As a regional, provider-owned health plan, SummaCare values the relationship between the members and their doctors. SummaCare is a part of Summa Health, an integrated healthcare delivery system that includes Summa Health System hospitals, its community-based health centers, dedicated clinicians and SummaCare. Based in Akron, Ohio, SummaCare provides Medicare Advantage, individual and family and commercial insurance plans. SummaCare has one of the highest rated Medicare Advantage plans in the state of Ohio, with a 4.5 out of 5-Star rating for 2025 by the Centers for Medicare and Medicaid Services (CMS). Known for its excellent customer service and personalized attention to members, SummaCare is committed to building lasting relationships. Employees can expect competitive pay and benefits. Summary: Accurately and efficiently handles claims in accordance with regulatory and contractual guidelines. Reviews claims related to coordination of benefits, medical coding, and authorization allocation while ensuring compliance with established policies. Applies cost-containment strategies in collaboration with vendor partners to minimize claim expenses while adhering to plan-specific processing rules. are essential for success in this position. 1. Formal Education Required: a. High School Diploma or equivalent 2. Experience & Training Required: a. One (1) year experience to include any combination of the following: i. Health insurance claims processing ii. Health claims data entry including Document Management Services (DMS) iii. Customer service experience in a managed care environment iv. Physician or hospital billing v. Patient accounts Essential Functions: 1. Requires close attention to detail with independent judgment, decision making and problem solving skills necessary to complete the task being performed 2. Organizes reference materials for easy access; manages time to accurately complete tasks within time frames in a fast paced environment 3. Processes all types of claims, promptly and accurately, as assigned via the document management system, and ensures self-funded service standards, prompt pay standards, and regulatory requirements are met. 4. Maintains a working knowledge of the claims processing system, imaging system, key-stroke emulation system, code editing application, claims processing policies & procedures, and unique benefits/processing rules for self-funded, Medicare, MEWA, Marketplace and fully-insured plans. 5. Escalates questions or concerns to their mentor for evaluation and potential referral to the Claims Management staff for action plan and resolution 6. Meets or exceeds claims production and quality standards as established/communicated by Claims Management staff 7. Coordinates information and resolves service forms and other assignments promptly, in accordance with experience/capabilities. Handles special projects within timeframes established/assigned by supervisor 3. Other Skills, Competencies and Qualifications: a. Strong independent judgment and decision-making skills b. MS-windows based computer environment c. Medical terminology, CPT, HCPCs and ICD-10 knowledge d. Familiar with professional (CMS1500) and institutional (UB-04) claim types 4. Level of Physical Demands: a. Sit for prolonged periods of time b. Bend, stop and stretch c. Lift up to 20 pounds d. Manual dexterity to operate computer, phone and standard office machines Equal Opportunity Employer/Veterans/Disabled $19.23/hr - $23.08/hr The salary range on this job posting/advertising is base salary exclusive of any bonuses or differentials. Many factors, such as years of relevant experience and geographical location are considered when determining the starting rate of pay. We believe in the importance of pay equity and consider internal equity of our current team members when determining offers. Please keep in mind that the range that is listed is the full base salary range. Hiring at the maximum of the range would not be typical. Summa Health offers a competitive and comprehensive benefits program to include medical, dental, vision, life, paid time off as well as many other benefits. * Basic Life and Accidental Death & Dismemberment (AD&D) * Supplemental Life and AD&D * Dependent Life Insurance * Short-Term and Long-Term Disability * Accident Insurance, Hospital Indemnity, and Critical Illness * Retirement Savings Plan * Flexible Spending Accounts - Healthcare and Dependent Care * Employee Assistance Program (EAP) * Identity Theft Protection * Pet Insurance * Education Assistance * Daily Pay

Job Title: Claims ProcessorJob Description This integral position helps bring resolution, determine appropriate next steps for client files, and manage client correspondence. It is a key role in ensuring smooth operations and client satisfaction. Responsibilities + Request and prepare legal documents using our case management system. + Reference court websites to obtain status updates on pending cases. + E-file complaints and motions with courts. + Update our case management system with judgment information. + Copy and scan documents. Essential Skills + Solid written and verbal communication skills. + Detail-oriented and organized. + Efficiently handle high work volume. + Ability to multi-task upon request. + Discretion in handling highly confidential matters and documents. Additional Skills & Qualifications + High School Diploma. + Intermediate knowledge of Microsoft Office. + Superior typing and data entry skills. Work Environment The position requires working onsite for an 8-hour shift between the hours of 7 AM and 6 PM. The work environment is conducive to productivity and is equipped with the necessary tools to perform duties effectively. Job Type & Location This is a Contract to Hire position based out of Akron, OH. Pay and Benefits The pay range for this position is $15.00 - $15.00/hr. Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following: - Medical, dental & vision - Critical Illness, Accident, and Hospital - 401(k) Retirement Plan - Pre-tax and Roth post-tax contributions available - Life Insurance (Voluntary Life & AD&D for the employee and dependents) - Short and long-term disability - Health Spending Account (HSA) - Transportation benefits - Employee Assistance Program - Time Off/Leave (PTO, Vacation or Sick Leave) Workplace Type This is a fully onsite position in Akron,OH. Application Deadline This position is anticipated to close on Feb 2, 2026. About Aston Carter: Aston Carter provides world-class corporate talent solutions to thousands of clients across the globe. Specialized in accounting, finance, human resources, talent acquisition, procurement, supply chain and select administrative professions, we extend the capabilities of industry-leading companies. We draw on our deep recruiting expertise and expansive network to meet the evolving needs of our clients and talent community with agility and excellence. With offices across the U.S., Canada, Asia Pacific and Europe, Aston Carter serves many of the Fortune 500. We are proud to be a ClearlyRated Best of Staffing double diamond winner for both client and talent service. The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law. If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please email astoncarteraccommodation@astoncarter.com (%20astoncarteraccommodation@astoncarter.com) for other accommodation options.

Provides support for provider claims adjudication activities including responding to providers to address claim issues, and researching, investigating and ensuring appropriate resolution of claims in a call center environment. * Respond to inbound calls to provide support for provider claims adjudication activities including responding to provider to address claim issues, and researching, investigating and ensuring appropriate resolution of claims. * Responds to incoming calls from providers regarding claims inquiries - provides excellent customer service, support and issue resolution; documents all calls and interactions. * Provides support for resolution of provider claims issues, including claims paid incorrectly; analyzes systems and collaborates with respective operational areas/provider billing to facilitate resolution. * Collaborates with the member enrollment, provider information management, benefits configuration and claims processing teams to appropriately address provider claim issues. * Assists in reviews of state and federal complaints related to claims. * Collaborates with other internal departments to determine appropriate resolution of claims issues. * Researches claims tracers, adjustments, and resubmissions of claims. * Adjudicates or re-adjudicates high volumes of claims in a timely manner. * Manages defect reduction by identifying and communicating claims error issues and potential solutions to leadership. * Meets claims department quality and production standards. * Supports claims department initiatives to improve overall claims function efficiency. * Completes basic claims projects as assigned. Required Qualifications * At least 2 years of experience in a clerical role in a claims, and/or customer service setting, including experience in provider claims investigation/research/resolution/reimbursement methodology analysis within a managed care organization, or equivalent combination of relevant education and experience. * Research and data analysis skills. * Organizational skills and attention to detail. * Time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines. * Customer service experience. * Effective verbal and written communication skills. * Microsoft Office suite and applicable software programs proficiency. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $21.65 - $38.37 / HOURLY * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

The Claims Specialist is responsible for providing prompt, effective assistance to clients and third parties reporting and settling claims with our agency. They also act as a liaison between the agency and carriers and assist others in the agency with service regarding claims activity. ESSENTIAL JOB RESPONSIBILITIES: To perform this job successfully, an individual must be able to perform each essential duty adequately. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Reports loss/claim information to the appropriate carrier the same day it is received. Gives prompt and courteous service on a same-day basis to all clients. Takes first reports of claims. Organizes claim information on forms and submits claim to appropriate carrier. Sets expectations of the claim process including time frames, deductibles, restoration companies and adjustors. Follows up with insurance companies for the timely and accurate settlement of losses. Responds to customers' inquiries and questions regarding the status of loss within 24 hours of inquiry. Follows all systems, procedures, and insurance company regulations. Authorizes claim payments within agency authority. Coordinates, as necessary, any activities between clients and claim adjusters. Complete weekly and monthly reports of claims notifications and updates. Notifies risk advisor and/or management of severe losses over $100,000. Provides updates to management and or appropriate risk advisor/customer service for clients with severe or frequent losses. Deals promptly and with full integrity with all carrier claims personnel, responding within 24 hours to any request for action or information Qualifications REQUIREMENTS: Knowledge, Skills, and Ability Extensive knowledge of claims procedures and insurance coverage Ability to satisfy the needs of the customer, both internal and external, needs little assistance from others in this endeavor Strong negotiating, decision-making, and relationship building skills Excellent customer service and teamwork skills Ability to interact with employees, customers and vendor companies Working knowledge of computer software packages including Microsoft Word, Excel and Outlook programs Ability to use general office equipment, including a computer, calculator, typewriter, fax machine, copier and telephone Ability to learn and perform new duties and responsibilities Education or Experience High school diploma. Bachelor's degree preferred. Must be willing to work toward industry designations Requires current driver's license Working Environment/ Physical Activities General office work environment. Requires regular use of arms, hands, and fingers. Frequently required to sit for extended periods of time, reach with arm and hands, stand, walk, stoop, talk and hear. Required to lift and/or move up to 10 pounds. Ability to work during regular business hours (8:00am-5:00pm), if required. Travel as needed. HIPAA Compliance This position may have access to Protected Health Information (PHI) and Electronic Protected Health Information (ePHI). An employee will be responsible for following the guidelines of the HIPAA Confidentiality Agreement. Note: This job description is not intended to be an exhaustive list of all duties, responsibilities, or qualifications associated with this job. The employee is expected to perform those duties listed as well as other related duties directed by management.

Marketing Statement: Philadelphia Insurance Companies, a member of the Tokio Marine Group, designs, markets and underwrites commercial property/casualty and professional liability insurance products for select industries. We have been in operation since 1962 and are nationally recognized as a member of Ward's Top 50 and rated A++ by A.M.Best. We are looking for a Claims Specialist - Auto to join our team. JOB SUMMARY Investigate, evaluate and settle more complex first and third party commercial insurance auto claims. JOB RESPONSIBILITIES Evaluates each claim in light of facts; Affirm or deny coverage; investigate to establish proper reserves; and settles or denies claims in a fair and expeditious manner. Communicates with all relevant parties and documents communication as well as results of investigation. Thoroughly understands coverages, policy terms and conditions for broad insurance areas, products or special contracts. Travel is required to attend customer service calls, mediations, and other legal proceedings. JOB REQUIREMENTS High School Diploma; Bachelor's degree from a four-year college or university preferred. 10 plus years related experience and/or training; or equivalent combination of education and experience. • National Range : $82,800.00 - $97,300.00 • Ultimate salary offered will be based on factors such as applicant experience and geographic location. EEO Statement: Tokio Marine Group of Companies (including, but not limited to the Philadelphia Insurance Companies, Tokio Marine America, Inc., TMNA Services, LLC, TM Claims Service, Inc. and First Insurance Company of Hawaii, Ltd.) is an Equal Opportunity Employer. In order to remain competitive we must attract, develop, motivate, and retain the most qualified employees regardless of age, color, race, religion, gender, disability, national or ethnic origin, family circumstances, life experiences, marital status, military status, sexual orientation and/or any other status protected by law. Benefits: We offer a comprehensive benefit package, which includes tuition reimbursement and a generous 401K match. Our rich history of outstanding results and growth allow us to focus our business plan on continued growth, new products, people development and internal career opportunities. If you enjoy working in a fast paced work environment with growth potential please apply online. Additional information on Volunteer Benefits, Paid Vacation, Medical Benefits, Educational Incentives, Family Friendly Benefits and Investment Incentives can be found at *****************************************

We offer a merit-based work-from-home program based on job responsibilities. After initial training in-person, you could have the flexibility of work-from-home time as defined by the leadership team. Auto-Owners Insurance, a top-rated insurance carrier, is seeking a motivated individual to join our Claims department as a Bodily Injury Claims Representative. The position requires the person to: * Assemble facts, determine coverage, evaluate the amount of loss, analyze legal liability, make payments in accordance with coverage, damage and liability determination, and perform other functions or duties to properly adjust the loss. * Study insurance policies, endorsements, and forms to develop an understanding of insurance coverage. * Follow claims handling procedures and participate in claim negotiations and settlements. * Deliver a high level of customer service to our agents, insureds, and others. * Devise alternative approaches to provide appropriate service, dependent upon the circumstances. * Meet with people involved with claims, sometimes outside of our office environment. * Handle investigations by telephone, email, mail, and on-site investigations. * Maintain appropriate adjuster's license(s), if required by statute in the jurisdiction employed, within the time frame prescribed by the Company or statute. * Handle complex and unusual exposure claims effectively through on-site investigations and through participation in mediations, settlement conferences, and trials. * Handle confidential information according to Company standards and in accordance with any applicable law, regulation, or rule. * Assist in the evaluation and selection of outside counsel. * Maintain punctual attendance according to an assigned work schedule at a Company approved work location. Desired Skills & Experience * A minimum of three years of insurance claims related experience. * The ability to organize and conduct an investigation involving complex issues and assimilate the information to reach a logical and timely decision. * The ability to effectively understand, interpret and communicate policy language. * The dissemination of appropriate claim handling techniques so that others involved in the claim process are understanding of issues. Benefits Auto-Owners offers a wide range of career opportunities, and we are seeking talent that will help us continue our long tradition of success. We offer a friendly work environment, structured training program, employee mentoring and an excellent compensation/benefits package. Along with a competitive base salary, matched 401(k), fully-funded pension plan (once vested), and bonus programs, Auto-Owners also provides generous paid time off including holidays, vacation days, personal time, and sick leave. If you're looking to do rewarding work alongside great people, Auto-Owners is the place for you! Equal Employment Opportunity Auto-Owners Insurance is an equal opportunity employer. The Company hires, transfers, and promotes on the basis of ability, without consideration of disability, age, sex, race, color, religion, height, weight, marital status, sexual orientation, gender identity or national origin, or any factor contrary to federal, state or local law. * Please note that the ability to work in the U.S. without current or future sponsorship is a requirement. #LI-DNI #IN-DNI

The Claims Specialist works on highly complex claim assignments requiring specialized knowledge. The role handles activities including, but not limited to, coverage analysis, liability and damage investigation, litigation, and expense management. The role also evaluates claims for reserve and settlement, executes settlement strategy, negotiates settlements proactively, attends arbitrations and ensures appropriate file documentation. Westfield Casualty Claims resolves third party liability claims involving injury, property damage, construction defect, personal & advertising injury, and environmental cleanup - both pre-suit and in litigation. Job Responsibilities Determines whether proper coverage exists for the type of claim assigned, investigates thoroughly to obtain relevant facts concerning coverage, liability, legal climate, potential exposure, and damages, and makes decisions on claim resolution. Determines the value of damage through physical inspections, uses appropriate tools, reviews policy coverages, inspects damages, determines cause and origin, investigates questionable circumstances, and considers subrogation and salvage possibilities. Establishes and reviews proper reserves for each claim based upon thorough investigation, evaluation, and experience. Completes appropriate reports so that the current status of the claim is clearly documented at all times. Assists claims professionals in the handling of large or complicated property losses. Participates in the coaching, development, training and education of claims professionals. Collaborates with property leadership team in the identification of property training needs. Assists in the design, development, and delivery of training to claims professionals. Provides outstanding customer service, works well with the insured and broker in the adjustment of mainstream risks, and claims. Collaborates in the defense and resolution of claims, reviews and analyzes contracts for risk transfer potential. Documents relevant events timely as case facts are developed, evaluates liability, damages, and exposure, negotiates timely settlements and refers claims exceeding authority to appropriate leader or complex claims specialist with recommendations. Provides general administrative, clerical and customer service assistance on the routine tasks to the Claims Adjustment team. Collaborates with internal and external business partners, large account customers, peers and other departments to make decisions that are in the best interest of the company. Remains current on industry topics, trends, processes, technology, best practices through research, industry events, networking, etc. Shares knowledge gained with others, drives new and updated policies, processes, and procedures. Supports and reports on the claims process improvement program, including the coordination and participation in best practice creation, monthly metric analysis etc. Supports catastrophe management efforts, organizes, deploys personnel, trains independent contractors, utilizes loss adjusting software and supports business partners by maintaining and enhancing relationships with customers and brokers. Travels as often as needed to cover assigned territory. This may involve traveling on short notice or other daily driving duties as assigned. Job Qualifications 6+ years of Claims Handling experience. Bachelor's Degree in Business or a related field and/or commensurate work experience. For field roles only: Valid driver's license and a driving record that conforms to company standards. Location Remote Licenses and Certifications Certified Professional Claims Management (CPCM) (preferred) Certified Claims Adjuster (CCA) (preferred) Chartered Property Casualty Underwriter (CPCU) (preferred) Behavioral Competencies Collaborates Communicates Effectively Customer Focus Decision Quality Nimble Learning Technical Skills Account Management Claims Investigations Claims Adjustment Claims Resolution Claims Settlement Financial Controls Auditing Claims Case Management Customer Relationship Management Business Process Improvement Auditing Data Analysis and Reporting This job description describes the general nature and level of work performed in this role. It is not intended to be an exhaustive list of all duties, skills, responsibilities, knowledge, etc. These may be subject to change and additional functions may be assigned as needed by management.

This role requires residency in Ohio or Indiana. The Casualty Claims Specialist manages high-exposure, multifaceted insurance claims requiring advanced skills in coverage analysis, litigation management, legal and medical document review, and negotiation to achieve economical, defensible resolutions. These roles involve working with minimal supervision, potentially mentoring others, and demands significant experience in complex claims handling and litigation. Salary Grade (13) 77,432 -98,727 -120,022 This role is responsible for determining coverage, assessing liability, establishing and adjusting reserves, evaluating claims, managing litigation, and negotiating settlements within assigned authority limits across multiple lines of business, including Homeowners, Personal Auto, Commercial Auto, Commercial Liability, Businessowners and Farm Liability. The Claims Specialist conducts thorough investigations to determine liability for all involved parties while delivering exceptional customer service that protects policyholders and safeguards company assets. Demonstrating strong expertise and sound judgment in complex matters, the Claims Specialist may serve as a subject matter expert and manages a designated caseload of casualty losses in compliance with company standards and applicable regulatory requirements (IC 27-4-1 / ORC 3901-1-54). Experience in analyzing, adjusting, and settling litigated claims under Homeowners, Personal Auto, Business Auto, Commercial General Liability, Businessowners, and Farm policies. Salary Grade (13) ESSENTIAL DUTIES AND RESPONSIBILITIES The following is a summary of the essential functions for this job. Other duties may be performed, both major and minor, which are not mentioned below. Specific activities may change from time to time. Coverage/Investigation/Liability - Determines whether proper coverage exists for the type of claim assigned. Investigates thoroughly to obtain relevant facts concerning all aspects of the claim, such as coverage, liability, legal climate, potential exposure, and damages, and makes decisions, where appropriate, on claim resolution. Monitors ongoing case development for appropriateness. Damages - Determines the value of the physical damage of property, automobiles, or injuries through physical inspections and use of appropriate tools. Obtains all necessary documentation to support claim evaluation. Recognizes claim file exposures and escalates appropriately. Reserving/Reporting - Establishes and reviews proper reserves for each claim based upon thorough investigation, evaluation, and experience. Completes appropriate reports so that the status of the claim is clearly documented at all times. Determines need for, and engages independent adjusters, cause and origin experts. independent medical examiners or other experts (e.g. reconstructionist, engineer). Proficiently and proactively handle the claim file through various phases of litigation. Independently review the applicability of coverage and civil law as well as local statutes. Attend mandatory and court ordered litigation events: mediation, pre-trial, trial. Keeps abreast of existing and proposed legislation, court decisions and trends and experience pertaining to coverage, liability and damages. May analyze the impact upon claims policies and procedures and advises Claims Management. Participates in or leads special projects and mentors others, as needed. Initiate prompt and effective communication with all parties having legal or contractual interest in claim presented Capable of drafting clear and concise letters and other correspondence. Accountable for security of financial processing of claims, as well as security information contained in claims files. Confers directly with policyholders on coverage and resolution issues pursuant to Home Office instructions. Prepare claims for trial, comply with trial alert procedures and notify/update reinsurance when appropriate. Participate in training programs, conferences and departmental and intra-departmental meetings. May be required to be on-call, on a limited basis, for afterhours emergencies Any other duties deemed necessary by supervisor or management. SUPERVISORY RESPONSIBILITIES None QUALIFICATIONS To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. EDUCATION and/or EXPERIENCE College Degree or Equivalent Experience At Least 3 years as a Sr. Claim Representative or equivalent preferred Excellent Written and Verbal Communication Skills Excellent Interpersonal Skills Superior Organizational Skills Efficient Time Management skills Ability to Demonstrate effective negotiation skills LANGUAGE SKILLS Excellent verbal and written communication skills. The individual must be able to effectively and clearly communicate with agents, insureds, departmental and company personnel via telephone, fax, e-mail, one-on-one dialogue and small group presentations in a professional manner. REASONING ABILITY The position requires the individual to apply common sense, understanding, reasoning and sound educated judgement coupled with sound Claims training and experience to properly evaluate and analyze claims for recommended action within assigned authority levels. CERTIFICATES, LICENSES, REGISTRATIONS IIA, AIC, or CPCU are highly preferred PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Employees are required to sit at a workstation to perform various PC functions. Additionally, the employee is required to devote substantial time to telephone communication. While performing the duties of this job, the employee is regularly required to sit and talk or hear. The employee frequently is required to use hands to finger, handle, or feel. The employee is occasionally required to stand, walk, and reach with hands and arms. Employees may be required to travel from time to time. This may require extended periods of time sitting in a vehicle. WORK ENVIRONMENT The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The Claim Specialist is responsible for the proper handling of claims. Each Claim Specialist will be assigned a specific work cubicle station and or other individual work areas. The workstation will be located adjacent to other similar workstations. The workstation has the necessary equipment to perform the position duties including personal computer, telephone, file space, and needed work table space. The environment is reasonably quiet with needed interaction between other team members, immediate supervisor, and other Company staff. Moderate noise level from telephone calls is expected.

A Third-Party Claims Supervisor is responsible for overseeing a team of claim representatives and claim specialists who manage claims made by individuals or entities against our clients. The core objective is to ensure that claims are handled accurately, efficiently, and in compliance with all relevant laws, regulations, and company policies, while also providing excellent customer service and team leadership. ESSENTIAL DUTIES & RESPONSIBILITIES: Includes, but is not limited to, the following: Team Supervision and Management: Supervise and manage a team of claims adjusters/specialists, including hiring, training, mentorship, coaching plans and performance evaluations. Claims Oversight: Oversee the start-to-end claims process, including intake, investigation, evaluation, negotiation, and settlement of claims. Quality Assurance & Compliance: Conduct regular quality audits of staff work to ensure compliance with company policies, procedures, and all applicable state and federal regulations. Complex Claim Resolution: Act as an escalation point for complex or contentious claims, assisting staff with coverage investigations, liability analysis, and settlement negotiations. Workflow & Efficiency: Monitor team workloads, manage diaries, and implement process improvements to optimize performance, productivity, and customer satisfaction. Communication & Reporting: Serve as a liaison between the company, clients, claimants, attorneys, and other third parties. Prepare and present reports on claim metrics, trends, and operational performance to management. Reserve Management: Ensure the appropriate and timely establishment and adjustment of claim reserves to reflect potential exposure. Litigation Support: Coordinate with the client, legal counsel and third-party administrators (TPAs) on litigated claims. Fraud Detection and Prevention: Monitor claims to identify potential fraud, referring suspicious activities to appropriate authorities and/or management. Data Analysis and Trend Identification: Analyze claims data and statistics to identify patterns, trends, and areas for process improvements or risk management strategies for clients and internal departments. Vendor and Service Partner Management: Manage relationships with external service providers such as independent adjusters, appraisers, and contractors, ensuring quality and cost-effectiveness of their services. Client Relationship Management (for TPAs): Serve as a primary point of contact for self-insured clients, providing detailed reports, participating in client reviews, and ensuring service level agreements (SLAs) are met. Mentorship and Professional Development: Create professional development plans for employees, provide ongoing technical advice and guidance to staff, and assist with their performance evaluations, promotion, retention, and termination activities. License Tracking and Record Keeping: Maintain an accurate and up-to-date database or system of all required department, facility, or individual employee licenses, permits, and certifications. This includes tracking expiration dates, status, and related documentation. Maintaining Licensing: Maintain insurance adjuster licensing as required in all states. QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. EDUCATION and/or EXPERIENCE: High School Diploma/GED: This is the basic minimum requirement for entry-level claims roles. Associate's or Bachelor's Degree: Most employers prefer candidates with a degree in Business Administration, Finance, Risk Management, Insurance, or a related field. Prior Claims Experience: A minimum of 2-5 years of technical experience in claims processing or adjusting is typically required. This experience should ideally involve handling complex or litigated claims, coverage investigations, and liability analysis. Supervisory/Leadership Experience: Previous experience in a supervisory, team lead, or mentorship role is highly preferred, demonstrating an ability to guide and manage a team. Industry-Specific Knowledge: Strong knowledge of specific claim types (e.g., general liability, commercial auto, property and casualty) and related regulations is essential. LICENSING: Ability to obtain and maintain insurance adjuster licensing as required in all states. ORAL COMMUNICATION SKILLS: Active Listening: This is arguably the most important skill. It involves fully concentrating on what is being said, understanding the message, and paying attention to non-verbal cues. This helps in collecting accurate information, showing empathy, and ensuring all parties feel heard. Clarity and Conciseness: The ability to convey complex information, such as insurance policies or claim decisions, in simple, straightforward language is crucial. Avoiding industry jargon and getting straight to the point prevents misunderstandings and saves time for all involved. Empathy and Emotional Intelligence: Claims often involve sensitive situations or frustrated individuals. Displaying empathy-acknowledging and sharing the feelings of others without necessarily agreeing with their position-helps de-escalate conflict and builds rapport. Tone, Volume, and Pacing: How you speak is as important as the words you use. A calm, confident, and respectful tone helps build credibility and ensures the message is received as intended, especially during difficult conversations. Pacing your speech to avoid talking too quickly also helps the listener process information. Confidence: Speaking with assurance demonstrates professionalism and competence. This doesn't mean being overbearing, but rather being prepared and assertive, which helps gain the trust of clients, team members, and management. Audience Awareness and Adaptability: Different situations and people require different communication styles. A conversation with a C-level executive might be formal and data-focused, while a discussion with a frustrated claimant might require a more patient and empathetic approach. Negotiation and Conflict Resolution: A claims supervisor frequently engages in negotiations and manages disagreements. Strong oral skills enable effective persuasion, working toward agreements, and resolving divergent interests in a constructive manner. Non-Verbal Communication: Body language, facial expressions, and eye contact play a significant role in communication. Maintaining appropriate eye contact and an open posture conveys engagement and honesty, while a lack of eye contact can imply disinterest or untrustworthiness. Giving and Receiving Feedback: Both providing constructive feedback to team members and accepting criticism from superiors or clients are vital. This fosters a culture of continuous improvement and open dialogue within the department. PREFERRED KNOWLEDGE, COMPENTENCIES & SKILLS: Leadership and Management: The ability to motivate, train, and mentor a team effectively, manage performance, and resolve conflicts. Analytical and Problem-Solving Skills: Essential for evaluating complex claims, identifying discrepancies, and making sound, data-driven decisions. Communication Skills: Excellent verbal and written communication skills are crucial for interacting with claimants, clients, legal counsel, and senior management. Attention to Detail: Meticulousness in reviewing documents, policy language, and regulations is vital to prevent errors and ensure compliance. Negotiation Skills: Strong ability to negotiate settlements effectively with various parties, including attorneys. Technical Proficiency: Competency with claims management software/systems (e.g., Guidewire, Duck Creek), Microsoft Office Suite (especially Excel for data analysis), and data analysis tools. Regulatory Knowledge: In-depth understanding of relevant state and federal insurance regulations and compliance standards. Deep Industry Knowledge: Comprehensive understanding of the insurance industry, including property & casualty, general liability, commercial auto, and workers' compensation lines of business. Claims Management Methodologies: Knowledge of best practices for claims investigation, evaluation, negotiation, subrogation, and resolution processes, including fraud detection techniques. MATHEMATICAL SKILLS: Basic Arithmetic and Calculation: The ability to perform fundamental operations (addition, subtraction, multiplication, division) quickly and accurately is essential for calculating damages, reviewing invoices, verifying expenses, and processing payments. Estimation: Using available data to estimate the potential future cost of a claim (setting reserves). Projections: Forecasting potential claim outcomes based on historical data and current trends. Metrics Review: Analyzing performance metrics, such as claim frequency, severity, closure rates, and loss ratios. Statistical Comprehension: Understanding basic statistics used in reports (e.g., averages, medians, percentages) to make informed decisions. Attention to Detail and Accuracy: Ensuring all calculations are performed without error is critical. A simple mistake in a calculation can lead to underpayment of a claimant, resulting in litigation, or overpayment of a claim, leading to financial loss for the company. Physical Demands and Working Conditions The worker is subject to inside environmental conditions: Protection from weather conditions but not necessarily from temperature changes. The worker is required to have close visual acuity to perform an activity such as: preparing and analyzing data and figures; transcribing; viewing a computer terminal; extensive reading.. Sedentary work: Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met. Talking: Expressing or exchanging ideas by means of the spoken word; those activities where detailed or important spoken instructions must be conveyed clearly and understandably both in person and over telephone. Hearing: Perceiving the nature of sounds at normal speaking levels with or without correction, and having the ability to receive detailed information through oral communication, and making fine discriminations in sound. Repetitive motions: Making substantial movements (motions) of the wrists, hands, and/or fingers. WORK SCHEDULE Flexible work arrangements available, two business days remote work after training completion. Standard schedule: Monday through Friday, 8:00AM - 5:00PM.

Pre-Certification Specialist - Southwoods Executive Centre Southwoods Health is hiring a Pre-Certification Specialist to work in our Authorizations Department in Boardman. The Pre-Certification Specialist will request and obtain authorizations for procedures and imaging ordered by Southwoods Health physicians. Essential Duties: Respond promptly to referral source requests for information, supporting documentation, or other report needs Obtain accurate and detailed information to begin investigating sources for payment and gather patient information Obtain authorization from payer sources to begin services. Assist in resolving insurance issues, re-authorization, and eligibility issues Responsible for obtaining and communicating pre-authorization as needed per insurance company requirements Responsible for tracking, obtaining, and extending authorizations from various carriers in a timely manner, requesting input from appropriate team members as needed Facilitate follow-up regarding ongoing services, eligibility, and authorization Communicate payer verification or benefit issues Record insurance information to maintain data and communicate insurance information to pertinent staff Maintain confidentiality of patient information Independently maintain and work from the electronic medical record and additional databases Obtain pre-certification number from physician's office if applicable Assist in the development, organization, and maintenance of role specific documents, policies, and tools Follow all federal, state, and regulatory guidelines to maintain compliance Ensure all processes at responsible physician practice maintains compliance with all regulatory agencies Perform other duties as assigned Qualifications: Training or courses in business office activities, computer skills, and medical terminology Effective communication skills, ability to problem solve, and great attention to detail Insurance Verification experience Minimum of 2 years' experience pre-authorizing medical procedure and imaging exams across modality and specialty (FP or IM office experience a plus) Full-time. Monday-Friday 8:30am-5:00pm. At Southwoods, it's not just about the treatment, but how you're treated. ************************

The Claims Specialist works on highly complex claim assignments requiring specialized knowledge. The role handles activities including, but not limited to, coverage analysis, liability and damage investigation, litigation, and expense management. The role also evaluates claims for reserve and settlement, executes settlement strategy, negotiates settlements proactively, attends arbitrations and ensures appropriate file documentation. Westfield Casualty Claims resolves third party liability claims involving injury, property damage, construction defect, personal & advertising injury, and environmental cleanup - both pre-suit and in litigation. Job Responsibilities Determines whether proper coverage exists for the type of claim assigned, investigates thoroughly to obtain relevant facts concerning coverage, liability, legal climate, potential exposure, and damages, and makes decisions on claim resolution. Determines the value of damage through physical inspections, uses appropriate tools, reviews policy coverages, inspects damages, determines cause and origin, investigates questionable circumstances, and considers subrogation and salvage possibilities. Establishes and reviews proper reserves for each claim based upon thorough investigation, evaluation, and experience. Completes appropriate reports so that the current status of the claim is clearly documented at all times. Assists claims professionals in the handling of large or complicated property losses. Participates in the coaching, development, training and education of claims professionals. Collaborates with property leadership team in the identification of property training needs. Assists in the design, development, and delivery of training to claims professionals. Provides outstanding customer service, works well with the insured and broker in the adjustment of mainstream risks, and claims. Collaborates in the defense and resolution of claims, reviews and analyzes contracts for risk transfer potential. Documents relevant events timely as case facts are developed, evaluates liability, damages, and exposure, negotiates timely settlements and refers claims exceeding authority to appropriate leader or complex claims specialist with recommendations. Provides general administrative, clerical and customer service assistance on the routine tasks to the Claims Adjustment team. Collaborates with internal and external business partners, large account customers, peers and other departments to make decisions that are in the best interest of the company. Remains current on industry topics, trends, processes, technology, best practices through research, industry events, networking, etc. Shares knowledge gained with others, drives new and updated policies, processes, and procedures. Supports and reports on the claims process improvement program, including the coordination and participation in best practice creation, monthly metric analysis etc. Supports catastrophe management efforts, organizes, deploys personnel, trains independent contractors, utilizes loss adjusting software and supports business partners by maintaining and enhancing relationships with customers and brokers. Travels as often as needed to cover assigned territory. This may involve traveling on short notice or other daily driving duties as assigned. Job Qualifications 6+ years of Claims Handling experience. Bachelor's Degree in Business or a related field and/or commensurate work experience. For field roles only: Valid driver's license and a driving record that conforms to company standards. Location Remote Licenses and Certifications Certified Professional Claims Management (CPCM) (preferred) Certified Claims Adjuster (CCA) (preferred) Chartered Property Casualty Underwriter (CPCU) (preferred) Behavioral Competencies Collaborates Communicates Effectively Customer Focus Decision Quality Nimble Learning Technical Skills Account Management Claims Investigations Claims Adjustment Claims Resolution Claims Settlement Financial Controls Auditing Claims Case Management Customer Relationship Management Business Process Improvement Auditing Data Analysis and Reporting This job description describes the general nature and level of work performed in this role. It is not intended to be an exhaustive list of all duties, skills, responsibilities, knowledge, etc. These may be subject to change and additional functions may be assigned as needed by management.

The Claims Specialist works on highly complex claim assignments requiring specialized knowledge. The role handles activities including, but not limited to, coverage analysis, liability and damage investigation, litigation, and expense management. The role also evaluates claims for reserve and settlement, executes settlement strategy, negotiates settlements proactively, attends arbitrations and ensures appropriate file documentation. Westfield Casualty Claims resolves third party liability claims involving injury, property damage, construction defect, personal & advertising injury, and environmental cleanup - both pre-suit and in litigation. Job Responsibilities * Determines whether proper coverage exists for the type of claim assigned, investigates thoroughly to obtain relevant facts concerning coverage, liability, legal climate, potential exposure, and damages, and makes decisions on claim resolution. * Determines the value of damage through physical inspections, uses appropriate tools, reviews policy coverages, inspects damages, determines cause and origin, investigates questionable circumstances, and considers subrogation and salvage possibilities. * Establishes and reviews proper reserves for each claim based upon thorough investigation, evaluation, and experience. * Completes appropriate reports so that the current status of the claim is clearly documented at all times. * Assists claims professionals in the handling of large or complicated property losses. * Participates in the coaching, development, training and education of claims professionals. * Collaborates with property leadership team in the identification of property training needs. * Assists in the design, development, and delivery of training to claims professionals. * Provides outstanding customer service, works well with the insured and broker in the adjustment of mainstream risks, and claims. * Collaborates in the defense and resolution of claims, reviews and analyzes contracts for risk transfer potential. * Documents relevant events timely as case facts are developed, evaluates liability, damages, and exposure, negotiates timely settlements and refers claims exceeding authority to appropriate leader or complex claims specialist with recommendations. * Provides general administrative, clerical and customer service assistance on the routine tasks to the Claims Adjustment team. * Collaborates with internal and external business partners, large account customers, peers and other departments to make decisions that are in the best interest of the company. * Remains current on industry topics, trends, processes, technology, best practices through research, industry events, networking, etc. * Shares knowledge gained with others, drives new and updated policies, processes, and procedures. * Supports and reports on the claims process improvement program, including the coordination and participation in best practice creation, monthly metric analysis etc. * Supports catastrophe management efforts, organizes, deploys personnel, trains independent contractors, utilizes loss adjusting software and supports business partners by maintaining and enhancing relationships with customers and brokers. * Travels as often as needed to cover assigned territory. * This may involve traveling on short notice or other daily driving duties as assigned. Job Qualifications * 6+ years of Claims Handling experience. * Bachelor's Degree in Business or a related field and/or commensurate work experience. * For field roles only: Valid driver's license and a driving record that conforms to company standards. Location Remote Licenses and Certifications * Certified Professional Claims Management (CPCM) (preferred) * Certified Claims Adjuster (CCA) (preferred) * Chartered Property Casualty Underwriter (CPCU) (preferred) Behavioral Competencies * Collaborates * Communicates Effectively * Customer Focus * Decision Quality * Nimble Learning Technical Skills * Account Management * Claims Investigations * Claims Adjustment * Claims Resolution * Claims Settlement * Financial Controls * Auditing * Claims Case Management * Customer Relationship Management * Business Process Improvement * Auditing * Data Analysis and Reporting This job description describes the general nature and level of work performed in this role. It is not intended to be an exhaustive list of all duties, skills, responsibilities, knowledge, etc. These may be subject to change and additional functions may be assigned as needed by management.

Who Are We? Taking care of our customers, our communities and each other. That's the Travelers Promise. By honoring this commitment, we have maintained our reputation as one of the best property casualty insurers in the industry for over 170 years. Join us to discover a culture that is rooted in innovation and thrives on collaboration. Imagine loving what you do and where you do it. Job Category Claim Compensation Overview The annual base salary range provided for this position is a nationwide market range and represents a broad range of salaries for this role across the country. The actual salary for this position will be determined by a number of factors, including the scope, complexity and location of the role; the skills, education, training, credentials and experience of the candidate; and other conditions of employment. As part of our comprehensive compensation and benefits program, employees are also eligible for performance-based cash incentive awards. Salary Range $67,000.00 - $110,600.00 Target Openings 1 What Is the Opportunity? This role is eligible for a sign on bonus. Be the Hero in Someone's Story When life throws curveballs - storms, accidents, unexpected challenges - YOU become the beacon of hope that guides our customers back to stability. At Travelers, our Claims Organization isn't just a department; it's the beating heart of our promise to be there when our customers need us most. As a Claim Rep, you will be responsible for managing, evaluating, and processing claims in a timely and accurate manner. In this detail-oriented and customer focused role, you will work closely with insureds to ensure claims are resolved efficiently while maintaining a high level of professionalism, empathy, and service throughout the claims handling process. What Will You Do? * Provide quality claim handling of auto claims including customer contacts, coverage, investigation, evaluation, reserving, negotiation, and resolution in accordance with company policies, compliance, and state specific regulations. * Communicate with policyholders, claimants, providers, and other stakeholders to gather information and provide updates. * Determine claim eligibility, coverage, liability, and settlement amounts. * Ensure accurate and complete documentation of claim files and transactions. * Identify and escalate potential fraud or complex claims for further investigation. * Coordinate with internal teams such as investigators, legal, and customer service, as needed. * In order to perform the essential functions of this job, acquisition and maintenance of Insurance License(s) may be required to comply with state and Travelers requirements. Generally, license(s) must be obtained within three months of starting the job and obtain ongoing continuing education credits as mandated. What Will Our Ideal Candidate Have? * Bachelor's Degree. * Three years of experience in insurance claims, preferably auto claims. * Experience with claims management and software systems. * Strong understanding of insurance principles, terminology with the ability to understand and articulate policies. * Strong analytical and problem-solving skills. * Proven ability to handle complex claims and negotiate settlements. * Exceptional customer service skills and a commitment to providing a positive experience for insureds and claimants. What is a Must Have? * One-year bodily injury liability claim handling experience or comparable liability claim handling experience, or successful completion of Travelers Claim Representative training program is required. What Is in It for You? * Health Insurance: Employees and their eligible family members - including spouses, domestic partners, and children - are eligible for coverage from the first day of employment. * Retirement: Travelers matches your 401(k) contributions dollar-for-dollar up to your first 5% of eligible pay, subject to an annual maximum. If you have student loan debt, you can enroll in the Paying it Forward Savings Program. When you make a payment toward your student loan, Travelers will make an annual contribution into your 401(k) account. You are also eligible for a Pension Plan that is 100% funded by Travelers. * Paid Time Off: Start your career at Travelers with a minimum of 20 days Paid Time Off annually, plus nine paid company Holidays. * Wellness Program: The Travelers wellness program is comprised of tools, discounts and resources that empower you to achieve your wellness goals and caregiving needs. In addition, our mental health program provides access to free professional counseling services, health coaching and other resources to support your daily life needs. * Volunteer Encouragement: We have a deep commitment to the communities we serve and encourage our employees to get involved. Travelers has a Matching Gift and Volunteer Rewards program that enables you to give back to the charity of your choice. Employment Practices Travelers is an equal opportunity employer. We value the unique abilities and talents each individual brings to our organization and recognize that we benefit in numerous ways from our differences. In accordance with local law, candidates seeking employment in Colorado are not required to disclose dates of attendance at or graduation from educational institutions. If you are a candidate and have specific questions regarding the physical requirements of this role, please send us an email so we may assist you. Travelers reserves the right to fill this position at a level above or below the level included in this posting. To learn more about our comprehensive benefit programs please visit *********************************************************

ATTENTION MILITARY AFFILIATED JOB SEEKERS - Our organization works with partner companies to source qualified talent for their open roles. The following position is available to Veterans, Transitioning Military, National Guard and Reserve Members, Military Spouses, Wounded Warriors, and their Caregivers . If you have the required skill set, education requirements, and experience, please click the submit button and follow the next steps. Taking care of our customers, our communities and each other. That's the Travelers Promise. By honoring this commitment, we have maintained our reputation as one of the best property casualty insurers in the industry for over 170 years. Join us to discover a culture that is rooted in innovation and thrives on collaboration. Imagine loving what you do and where you do it. Job Category Claim Compensation Overview The annual base salary range provided for this position is a nationwide market range and represents a broad range of salaries for this role across the country. The actual salary for this position will be determined by a number of factors, including the scope, complexity and location of the role; the skills, education, training, credentials and experience of the candidate; and other conditions of employment. As part of our comprehensive compensation and benefits program, employees are also eligible for performance-based cash incentive awards. Salary Range $67,000.00 - $110,600.00 What Is the Opportunity? This position is responsible for handling Personal and Business Insurance Auto Bodily Injury claims from the first notice of loss through resolution/settlement and payment process. This may include interpreting and applying laws and statutes for multiple state jurisdictions. Claim types include moderate complexity Bodily Injury claims. Provides quality claim handling throughout the claim life cycle (customer contacts, coverage, investigation, evaluation, reserving, negotiation and resolution) including maintaining full compliance with internal and external quality standards and state specific regulations. What Will You Do? Customer Contacts/Experience: Delivers consistent service quality throughout the claim life cycle, including but not limited to prompt contact, explaining the process, setting expectations, on-going communication, follow-through and meeting commitments to achieve optimal outcome on every file. Fulfills specific service commitments made to certain accounts, as outlined in Special Account Communication (SAC) instructions. Coverage Analysis : Reviews and analyzes coverage and applies policy conditions, provisions, exclusions and endorsements for moderate complexity Bodily Injury liability claims in assigned jurisdictions. Verifies the benefits available, the injured party's eligibility and the applicable limits. Addresses proper application of any deductibles, co-insurance, coverage limits, etc. Confirms priority of coverage (i.e. primary, secondary, concurrent) and takes into consideration issues such as Social Security, Workers Compensation or others relevant to the jurisdiction. Consults with Unit Manager on use of Claim Coverage Counsel. Investigation/Evaluation: Investigates each claim to obtain relevant facts necessary to determine coverage, the extent of liability, damages, and contribution potential with respect to the various coverages provided through prompt contact with appropriate parties (e.g. policyholders, accounts, claimants, law enforcement agencies, witnesses, agents, medical providers and technical experts). This may also include investigation of wage loss and essential services claims. Verifies the nature and extent of injury or property damage by obtaining and reviewing appropriate records and damages documentation. Takes recorded statements as necessary. Utilizes evaluation documentation tools in accordance with department guidelines. Identifies resources for specific activities required to properly investigate claims such as Subrogation, Risk Control, nurse consultants, and fire or fraud investigators and to other experts. Requests through Unit Manager and coordinate the results of their efforts and findings. Recognizes cases based on severity protocols to be referred timely to next level claim professional or Major Case Unit. Reserving: Establishes timely and maintains appropriate claim and expense reserves. Manages file inventory and expense reserves by utilizing an effective diary system, documenting claim file activities in accordance with established procedures to resolve claim in a timely manner. Negotiation/Resolution: Determines settlement amounts, negotiates and conveys claim settlements within authority limits to claimants or their representatives. Recognizes and implements alternate means of resolution. As appropriate, writes denial letters, Reservation of Rights and other necessary correspondence to claimants. Handles both unrepresented and attorney represented claims. May manage litigated claims on appropriately assigned cases. Develops litigation plan with staff or panel counsel, track and control legal expenses. May attend depositions, mediations, arbitrations, pre-trials, trials and all other legal proceedings, as needed. Insurance License: In order to perform the essential functions of this job, acquisition and maintenance of Insurance License(s) may be required to comply with state and Travelers requirements. Generally, license(s) must be obtained within three months of starting the job and obtain ongoing continuing education credits as mandated. Perform other duties as assigned. Additional Qualifications/Responsibilities What Will Our Ideal Candidate Have? Bachelor's Degree. 2 years bodily injury liability claim handling experience. General knowledge and skill in claims handling and litigation. Basic working level knowledge and skill in various business line products. Demonstrated ownership attitude and customer centric response to all assigned tasks. Demonstrated good organizational skills with the ability to prioritize and work independently. Attention to detail ensuring accuracy. Keyboard skills and Windows proficiency, including Excel and Word - Intermediate. Verbal and written communication skills - Intermediate. Analytical Thinking- Intermediate. Judgment/Decision Making- Intermediate. Negotiation- Intermediate. Insurance Contract Knowledge- Intermediate. Principles of Investigation- Intermediate. Value Determination- Intermediate. Settlement Techniques- Intermediate. Medical Knowledge- Intermediate. What is a Must Have? One-year bodily injury liability claim handling experience or comparable liability claim handling experience, or successful completion of Travelers Claim Representative training program is required.

At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. **Position Summary** Reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with plan processing guidelines. Acts as a subject matter expert by providing training, coaching, or responding to complex issues. May handle customer service inquiries and problems. **Additional Responsibilities:** Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing expertise. - Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment. measures to assist in the claim adjudication process. - Handles phone and written inquiries related to requests for pre-approval/pre-authorization, reconsiderations, or appeals. - Ensures all compliance requirements are satisfied and all payments are made against company practices and procedures. - Identifies and reports possible claim overpayments, underpayments and any other irregularities. - Performs claim rework calculations. - Distributes work assignment daily to junior staff. - Trains and mentors claim benefit specialists.- Makes outbound calls to obtain required information for claim or reconsideration. **Required Qualifications** - New York Independent Adjuster License - Experience in a production environment. - Demonstrated ability to handle multiple assignments competently, accurately and efficiently. **Preferred Qualifications** - 18+ months of medical claim processing experience - Self-Funding experience - DG system knowledge **Education** **-** High School Diploma required - Preferred Associates degree or equivalent work experience. **Anticipated Weekly Hours** 40 **Time Type** Full time **Pay Range** The typical pay range for this role is: $18.50 - $42.35 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. **Great benefits for great people** We take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: + **Affordable medical plan options,** a **401(k) plan** (including matching company contributions), and an **employee stock purchase plan** . + **No-cost programs for all colleagues** including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. + **Benefit solutions that address the different needs and preferences of our colleagues** including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit ***************************************** We anticipate the application window for this opening will close on: 02/27/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. CVS Health is an equal opportunity/affirmative action employer, including Disability/Protected Veteran - committed to diversity in the workplace.

Provides support for provider claims adjudication activities including responding to providers to address claim issues, and researching, investigating and ensuring appropriate resolution of claims. * Provides support for resolution of provider claims issues, including claims paid incorrectly; analyzes systems and collaborates with respective operational areas/provider billing to facilitate resolution. * Collaborates with the member enrollment, provider information management, benefits configuration and claims processing teams to appropriately address provider claim issues. * Responds to incoming calls from providers regarding claims inquiries - provides excellent customer service, support and issue resolution; documents all calls and interactions. * Assists in reviews of state and federal complaints related to claims. * Collaborates with other internal departments to determine appropriate resolution of claims issues. * Researches claims tracers, adjustments, and resubmissions of claims. * Adjudicates or readjudicates high volumes of claims in a timely manner. * Manages defect reduction by identifying and communicating claims error issues and potential solutions to leadership. * Meets claims department quality and production standards. * Supports claims department initiatives to improve overall claims function efficiency. * Completes basic claims projects as assigned. Required Qualifications * At least 2 years of experience in a clerical role in a claims, and/or customer service setting, including experience in provider claims investigation/research/resolution/reimbursement methodology analysis within a managed care organization, or equivalent combination of relevant education and experience. * Research and data analysis skills. * Organizational skills and attention to detail. * Time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines. * Customer service experience. * Effective verbal and written communication skills. * Microsoft Office suite and applicable software programs proficiency. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $21.65 - $38.37 / HOURLY * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Job Description A Third-Party Claims Supervisor is responsible for overseeing a team of claim representatives and claim specialists who manage claims made by individuals or entities against our clients. The core objective is to ensure that claims are handled accurately, efficiently, and in compliance with all relevant laws, regulations, and company policies, while also providing excellent customer service and team leadership. ESSENTIAL DUTIES & RESPONSIBILITIES: Includes, but is not limited to, the following: Team Supervision and Management: Supervise and manage a team of claims adjusters/specialists, including hiring, training, mentorship, coaching plans and performance evaluations. Claims Oversight: Oversee the start-to-end claims process, including intake, investigation, evaluation, negotiation, and settlement of claims. Quality Assurance & Compliance: Conduct regular quality audits of staff work to ensure compliance with company policies, procedures, and all applicable state and federal regulations. Complex Claim Resolution: Act as an escalation point for complex or contentious claims, assisting staff with coverage investigations, liability analysis, and settlement negotiations. Workflow & Efficiency: Monitor team workloads, manage diaries, and implement process improvements to optimize performance, productivity, and customer satisfaction. Communication & Reporting: Serve as a liaison between the company, clients, claimants, attorneys, and other third parties. Prepare and present reports on claim metrics, trends, and operational performance to management. Reserve Management: Ensure the appropriate and timely establishment and adjustment of claim reserves to reflect potential exposure. Litigation Support: Coordinate with the client, legal counsel and third-party administrators (TPAs) on litigated claims. Fraud Detection and Prevention: Monitor claims to identify potential fraud, referring suspicious activities to appropriate authorities and/or management. Data Analysis and Trend Identification: Analyze claims data and statistics to identify patterns, trends, and areas for process improvements or risk management strategies for clients and internal departments. Vendor and Service Partner Management: Manage relationships with external service providers such as independent adjusters, appraisers, and contractors, ensuring quality and cost-effectiveness of their services. Client Relationship Management (for TPAs): Serve as a primary point of contact for self-insured clients, providing detailed reports, participating in client reviews, and ensuring service level agreements (SLAs) are met. Mentorship and Professional Development: Create professional development plans for employees, provide ongoing technical advice and guidance to staff, and assist with their performance evaluations, promotion, retention, and termination activities. License Tracking and Record Keeping: Maintain an accurate and up-to-date database or system of all required department, facility, or individual employee licenses, permits, and certifications. This includes tracking expiration dates, status, and related documentation. Maintaining Licensing: Maintain insurance adjuster licensing as required in all states. QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. EDUCATION and/or EXPERIENCE: High School Diploma/GED: This is the basic minimum requirement for entry-level claims roles. Associate's or Bachelor's Degree: Most employers prefer candidates with a degree in Business Administration, Finance, Risk Management, Insurance, or a related field. Prior Claims Experience: A minimum of 2-5 years of technical experience in claims processing or adjusting is typically required. This experience should ideally involve handling complex or litigated claims, coverage investigations, and liability analysis. Supervisory/Leadership Experience: Previous experience in a supervisory, team lead, or mentorship role is highly preferred, demonstrating an ability to guide and manage a team. Industry-Specific Knowledge: Strong knowledge of specific claim types (e.g., general liability, commercial auto, property and casualty) and related regulations is essential. LICENSING: Ability to obtain and maintain insurance adjuster licensing as required in all states. ORAL COMMUNICATION SKILLS: Active Listening: This is arguably the most important skill. It involves fully concentrating on what is being said, understanding the message, and paying attention to non-verbal cues. This helps in collecting accurate information, showing empathy, and ensuring all parties feel heard. Clarity and Conciseness: The ability to convey complex information, such as insurance policies or claim decisions, in simple, straightforward language is crucial. Avoiding industry jargon and getting straight to the point prevents misunderstandings and saves time for all involved. Empathy and Emotional Intelligence: Claims often involve sensitive situations or frustrated individuals. Displaying empathy-acknowledging and sharing the feelings of others without necessarily agreeing with their position-helps de-escalate conflict and builds rapport. Tone, Volume, and Pacing: How you speak is as important as the words you use. A calm, confident, and respectful tone helps build credibility and ensures the message is received as intended, especially during difficult conversations. Pacing your speech to avoid talking too quickly also helps the listener process information. Confidence: Speaking with assurance demonstrates professionalism and competence. This doesn't mean being overbearing, but rather being prepared and assertive, which helps gain the trust of clients, team members, and management. Audience Awareness and Adaptability: Different situations and people require different communication styles. A conversation with a C-level executive might be formal and data-focused, while a discussion with a frustrated claimant might require a more patient and empathetic approach. Negotiation and Conflict Resolution: A claims supervisor frequently engages in negotiations and manages disagreements. Strong oral skills enable effective persuasion, working toward agreements, and resolving divergent interests in a constructive manner. Non-Verbal Communication: Body language, facial expressions, and eye contact play a significant role in communication. Maintaining appropriate eye contact and an open posture conveys engagement and honesty, while a lack of eye contact can imply disinterest or untrustworthiness. Giving and Receiving Feedback: Both providing constructive feedback to team members and accepting criticism from superiors or clients are vital. This fosters a culture of continuous improvement and open dialogue within the department. PREFERRED KNOWLEDGE, COMPENTENCIES & SKILLS: Leadership and Management: The ability to motivate, train, and mentor a team effectively, manage performance, and resolve conflicts. Analytical and Problem-Solving Skills: Essential for evaluating complex claims, identifying discrepancies, and making sound, data-driven decisions. Communication Skills: Excellent verbal and written communication skills are crucial for interacting with claimants, clients, legal counsel, and senior management. Attention to Detail: Meticulousness in reviewing documents, policy language, and regulations is vital to prevent errors and ensure compliance. Negotiation Skills: Strong ability to negotiate settlements effectively with various parties, including attorneys. Technical Proficiency: Competency with claims management software/systems (e.g., Guidewire, Duck Creek), Microsoft Office Suite (especially Excel for data analysis), and data analysis tools. Regulatory Knowledge: In-depth understanding of relevant state and federal insurance regulations and compliance standards. Deep Industry Knowledge: Comprehensive understanding of the insurance industry, including property & casualty, general liability, commercial auto, and workers' compensation lines of business. Claims Management Methodologies: Knowledge of best practices for claims investigation, evaluation, negotiation, subrogation, and resolution processes, including fraud detection techniques. MATHEMATICAL SKILLS: Basic Arithmetic and Calculation: The ability to perform fundamental operations (addition, subtraction, multiplication, division) quickly and accurately is essential for calculating damages, reviewing invoices, verifying expenses, and processing payments. Estimation: Using available data to estimate the potential future cost of a claim (setting reserves). Projections: Forecasting potential claim outcomes based on historical data and current trends. Metrics Review: Analyzing performance metrics, such as claim frequency, severity, closure rates, and loss ratios. Statistical Comprehension: Understanding basic statistics used in reports (e.g., averages, medians, percentages) to make informed decisions. Attention to Detail and Accuracy: Ensuring all calculations are performed without error is critical. A simple mistake in a calculation can lead to underpayment of a claimant, resulting in litigation, or overpayment of a claim, leading to financial loss for the company. Physical Demands and Working Conditions The worker is subject to inside environmental conditions: Protection from weather conditions but not necessarily from temperature changes. The worker is required to have close visual acuity to perform an activity such as: preparing and analyzing data and figures; transcribing; viewing a computer terminal; extensive reading.. Sedentary work: Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met. Talking: Expressing or exchanging ideas by means of the spoken word; those activities where detailed or important spoken instructions must be conveyed clearly and understandably both in person and over telephone. Hearing: Perceiving the nature of sounds at normal speaking levels with or without correction, and having the ability to receive detailed information through oral communication, and making fine discriminations in sound. Repetitive motions: Making substantial movements (motions) of the wrists, hands, and/or fingers. WORK SCHEDULE Flexible work arrangements available, two business days remote work after training completion. Standard schedule: Monday through Friday, 8:00AM - 5:00PM.

Provides support for provider claims adjudication activities including responding to providers to address claim issues, and researching, investigating and ensuring appropriate resolution of claims in a call center environment. - Respond to inbound calls to provide support for provider claims adjudication activities including responding to provider to address claim issues, and researching, investigating and ensuring appropriate resolution of claims. - Responds to incoming calls from providers regarding claims inquiries - provides excellent customer service, support and issue resolution; documents all calls and interactions. - Provides support for resolution of provider claims issues, including claims paid incorrectly; analyzes systems and collaborates with respective operational areas/provider billing to facilitate resolution. - Collaborates with the member enrollment, provider information management, benefits configuration and claims processing teams to appropriately address provider claim issues. - Assists in reviews of state and federal complaints related to claims. - Collaborates with other internal departments to determine appropriate resolution of claims issues. - Researches claims tracers, adjustments, and resubmissions of claims. - Adjudicates or re-adjudicates high volumes of claims in a timely manner. - Manages defect reduction by identifying and communicating claims error issues and potential solutions to leadership. - Meets claims department quality and production standards. - Supports claims department initiatives to improve overall claims function efficiency. - Completes basic claims projects as assigned. **Required Qualifications** - At least 2 years of experience in a clerical role in a claims, and/or customer service setting, including experience in provider claims investigation/research/resolution/reimbursement methodology analysis within a managed care organization, or equivalent combination of relevant education and experience. - Research and data analysis skills. - Organizational skills and attention to detail. -Time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines. - Customer service experience. - Effective verbal and written communication skills. - Microsoft Office suite and applicable software programs proficiency. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $21.65 - $38.37 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Provides support for provider claims adjudication activities including responding to providers to address claim issues, and researching, investigating and ensuring appropriate resolution of claims. - Provides support for resolution of provider claims issues, including claims paid incorrectly; analyzes systems and collaborates with respective operational areas/provider billing to facilitate resolution. - Collaborates with the member enrollment, provider information management, benefits configuration and claims processing teams to appropriately address provider claim issues. - Responds to incoming calls from providers regarding claims inquiries - provides excellent customer service, support and issue resolution; documents all calls and interactions. - Assists in reviews of state and federal complaints related to claims. - Collaborates with other internal departments to determine appropriate resolution of claims issues. - Researches claims tracers, adjustments, and resubmissions of claims. - Adjudicates or readjudicates high volumes of claims in a timely manner. - Manages defect reduction by identifying and communicating claims error issues and potential solutions to leadership. - Meets claims department quality and production standards. - Supports claims department initiatives to improve overall claims function efficiency. - Completes basic claims projects as assigned. **Required Qualifications** - At least 2 years of experience in a clerical role in a claims, and/or customer service setting, including experience in provider claims investigation/research/resolution/reimbursement methodology analysis within a managed care organization, or equivalent combination of relevant education and experience. - Research and data analysis skills. - Organizational skills and attention to detail. -Time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines. - Customer service experience. - Effective verbal and written communication skills. - Microsoft Office suite and applicable software programs proficiency. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $21.65 - $38.37 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.