Claim Processor Jobs in Fremont, CA

JT2 has over two decades of experience in claims administration and has delivered consistent cost savings to clients while providing quality care to claimants. We partner with our clients to provide fully customized and innovative solutions that integrate claims administration with risk control solutions. We are searching for highly motivated Claims Examiners to join our team! Under supervision of the Claims Supervisor, the Claims Examiner will manage claims from inception to conclusion. The position requires an individual that adheres to best practices and State of California statutes to work directly with clients, injured workers, agents, vendors, and attorneys to resolve workers compensation claims. This position is available for either remote or in office work. Minimum Requirements Three (3) years of claims management experience Bachelor's degree from an accredited college or university preferred. Possession of a current Self-Insurance Plan (SIP) Certificate and insurance-related course work: CPCU, WCCA, WCCP, ARM. Ability to administer any type of indemnity claim within the assigned caseload including those involving lost time, permanent disability residuals, and future medical claims. Duties and Responsibilities Ensure proper handling of claims from inception to conclusion per client service agreements and JT2 service standards. Prepare accurate and timely issuance of benefits notices and required reports within statutory limits. Reserve files in compliance with injury type; identify potential costs of medical care investigation and indemnity benefits. Ensure timely payment of benefits, bills and appropriate caseload and performance goals. Negotiate and prepare claims for settlement; provide manager/supervisor with complete and accurate settlement data. Monitor, report, and assign claims for fraud potential and subrogation possibilities. Monitor claims for pre-established criteria for case-management and vocational rehabilitation in accordance with State laws. Prepare and present claims summaries to clients during file reviews. Train and direct Claims Assistants to meet goals and deadlines. Review and approve priority payments and other documents from Claims Assistants. Performs other duties as assigned Knowledge, Skills, and Abilities Strong knowledge of workers' compensation policy, concepts and terminology and benefit provisions. Strong knowledge of adjusting workers' compensation claims for municipalities and administering LC 4850 benefits. Strong skills with use of general office administration technology, including Microsoft Office Suite and related software Excellent verbal and written communication skills Excellent interpersonal and conflict resolution skills Excellent organizational skills and attention to detail Excellent interpersonal, negotiation, and conflict resolution skills Strong analytical and problem-solving skills Ability to act with integrity, professionalism, and confidentiality, at all times The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities from time to time, as needed. JT2 Integrated Resources provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

At Republic Indemnity, we've been helping businesses in the western U.S. manage their Workers' Compensation costs for over 50 years. Headquartered in Calabasas, California with additional offices in San Francisco and San Diego, we write workers compensation primarily in CA with significant business in AK, AZ, NV, and other western states. Whether it's helping a broker, policyholder, injured worker, or a colleague, Republic is all about creating a clear way forward so people can reach their goals. If you share that vision, we'd love to talk with you about our exiting opportunity for Workers' Compensation Claims Specialist. This position is based in our San Francisco office with a hybrid schedule of a minimum 1 day in the office per week. Essential Job Functions and Responsibilities: Investigates and maintains claims. Reviews and evaluates coverage and/or liability. Secures and analyzes necessary information (i.e., reports, policies, appraisals, releases, statements, records, or other documents) in the investigation of claims. Works toward the resolution of claims files, and attends arbitrations, mediations, depositions or trials as necessary. May affect settlements/reserves within prescribed limits and submit recommendations to supervisor on cases exceeding personal authority. Conveys complex information (coverage, decisions, outcomes, etc.) to all appropriate parties, maintaining a professional demeanor in all situations. Ensures that claims payments are issued in a timely and accurate manner. Ensures that claims handling is conducted in compliance with applicable statutes, regulations and other legal requirements, and that all applicable company procedures and policies are followed. Provides technical advice to lower level positions and other functional areas. May have responsibility for performance and coaching of staff and may have a participatory role in decisions regarding talent selection, development, and performance management for direct reports. Performs other duties as assigned. Qualifications: Bachelor's Degree or equivalent experience. Generally, 6-10 years of experience handling California workers' comp claims. Must be detail oriented with strong organizational skills.

Job Details Experienced Concord Office - Concord, CA Hybrid Full Time High School Diploma or GED $90,000.00 - $95,000.00 Salary/year None Day InsuranceClaims Examiner III _Hybrid will be Hybrid. Working 2 days in the office, 3 days from home. Be sure to navigate to the end of the application and sign it. JOB SUMMARY: Investigates, evaluates, disposes and settles moderately complex to complex/high exposure claims. Includes the investigation, evaluation and determination of coverage, compensability and responsibility and the setting of proper reserves. DUTIES AND RESPONSIBILITIES: Processes moderately complex to complex or high exposure claims consistent with clients' and corporate policies, procedures and “Best Practices” and in accordance with any statutory, regulatory and ethics requirements. Independently analyzes claim exposure, determines a proper plan of action to appropriately mitigate and settle/close the claim working within established level of authority. Interacts with injured workers, client contacts and attending Physician(s) to ensure awareness and understanding of the Workers' Compensation process, requirements and entitlements. Interacts with disability and leave examiners for coordination of non-occupational benefits. Prepares and issues notices in accordance with mandated requirements and regularly reviews and stays abreast of applicable laws, rules and regulations that may impact how claims are processed. Establishes and maintains proper reserving throughout the life of the claim. Identify subrogation potential and pursue the process for reimbursement. Complies with carrier excess reporting and threshold requirements. Coordinates medical treatment for injured workers and provides information to treating physician(s) regarding the employee's medical history, health issues and job requirements. Fully understands Medicare reporting requirements as they relate to a Workers' Compensation claim. Facilitates early RTW through temporary, transitional, alternate, or modified work. Manages all medical aspects of a claim file with a focus on RTW and end of treatment. Refers appropriate files for task management assignments to approved vendors for medical management, special investigative needs, conditional payments, etc. up to assigned authority. Monitors status and quality of work performed. Serves as a liaison between medical providers, employees, legal professionals, clients and vendors. Independently manages claims in litigation with regular and consistent communication with defense counsel to make recommendations and develop strategy. Enters and maintains accurate information in the claims management computer system. Clearly communicates concise action plans and present plans for moving the claim to resolution. Meets with clients to discuss on-going claims or review open claim inventory. Effectively controls expenses on all Workers' Compensation claims. Mentors first level WC Examiners. All other duties as assigned. Qualifications QUALIFICATIONS REQUIRED: Education: High School Diploma or GED required: Bachelor's degree in related field (strongly preferred) or equivalent combination of education and experience. Experience: Three (3) to five (5) years of Workers' Compensation Claims administration experience required working with self-insured and/or insured claims. Licenses/Certificate: SIP Preferred Skills: Demonstrated experience working with complex, high exposure and litigated WC claims. Appropriately licensed and/or certified in all States in which claims are being handled. Multi-Jurisdiction experience is a (+). Bilingual Spanish is a (+) Able to work in a fast paced, high stress, changing environment. Strong analytical, critical thinking and problem-solving skills required. Effective verbal and written communication skills required. Excellent planning, organizing and negotiation skills required. Attention to detail. Negotiation and interpretive skills necessary. Demonstrated knowledge of established claims strategy and mitigation techniques. Establishes and maintains effective working relationships with those contacted in the course of work. Proficiency with computers and technology - working knowledge of Microsoft Office application suite (MS Word, Excel, etc. and familiarity and experience using standard claims administration applications. Good interpersonal skills with an ability to work within a team environment. Able to effectively handle multiple priorities simultaneously. Works independently. Here is some of the benefits you can enjoy in this role Medical, Dental, Vision, Life insurance & Disability 401 (k) plan Paid holidays. Paid time off. Mental and Physical Requirements: [see separate attachment for a copy of checklist of mental and physical requirements] MENTAL AND PHYSICAL REQUIREMENTS 1. MENTAL EFFORT a. Reasoning development: Follow one- or two-step instructions; routine, repetitive task. Carry out detail but uninvolved written or verbal instructions; deal with a few concrete variables. Follow written, verbal, or diagrammatic instructions; several concrete variables. X Solve practical problems; variety of variables with limited standardization; interpret instructions. Logical or scientific thinking to solve problems; several abstract and concrete variables. Wide range of intellectual and practical problems; comprehend most obscure concepts. b. Mathematical development: Simple additional and subtraction; copying figures, counting, and recording. Add, subtract, multiply, and divide whole numbers. X Arithmetic calculations involving fractions, decimals, and percentages. Arithmetic, algebraic, and geometric calculations. Advanced mathematical and statistical techniques such as calculus, factor analysis, and probability determination. Highly complex mathematical and statistical techniques such as calculus, factor analysis, and probability determination; requires theoretical application.

Share **Claims Examiner IV** 30+ days ago Requisition ID: 1071 Salary Range: $69,000.00 To $146,000.00 Annually **Claims Examiner IV** **Summary** Reporting to the Claims Manager and working independently and with great latitude for independent action, this position manages an inventory consisting primarily of claims with higher loss potential and complexity, and commensurate reserving, settlement authority, reinsurance reporting requirements, as well as claims of lesser exposure or severity as dictated by the needs of the department. Investigates, evaluates and settles claims within designated authority. Occasionally assigns and directs Independent Adjusters/Appraisers and regularly assigns and directs defense attorneys. The ideal candidate would have 10+ years carrier experience and be capable of working independently as well as collaboratively and have prior experience working remotely from a home office. In this position, thorough knowledge and experience is assumed for one or more standard casualty lines, or for demonstrated experience in Property claims. **Responsibilities** The Claims Examiner IV responsibilities include but are not limited to: * Determines coverage(s) applicable to loss. * Investigates, manages and resolves claims in a timely, unbiased and informed manner in compliance with company policies, state laws and regulatory performance standards. * Sets and maintains adequate claim reserves based on facts of case and in accordance with company policy. * Conducts investigation, assigning fieldwork as necessary and appropriate, in accordance with company standards. * Determines liability. * Evaluates and pays claims within designated authority. * When requested, present coverage and claims analysis to management and make recommendations on resolution of disputed items. * Set reserves up to the positions level of authority. * Prepares and presents verbal and written claim status reports in accordance with company policy and pursuant to Reinsurance treaty requirements. * Recommends payment, evaluates and reserves claims and reports to manager cases in excess of designated authority, as well as to Reinsurers pursuant to treaty requirements. * Manages legal aspects through timely assignment of litigated cases to defense counsel, and on-going evaluation of legal process and expenses. * Maintain electronic files necessary for documentation of the claim file. * Analyzes and regularly reports to Claims Manager on the performance of defense counsel. * Represents the company at litigation related settlement conferences, mediation, and arbitration when needed. * Works closely with outside counsel to monitor claims and work with insureds to resolve underlying litigation * Participates in both internal and external audits as needed * Participates in weekly department meetings and Claims Committee Meetings as needed * Promote the team approach to case and account management. * Participates in marketing presentations and training programs as needed. * Provide accurate, courteous and timely information to all external and internal customers concerning claims status and other inquiries. * Other duties as assigned **Required Competencies** * Requires highly technical claim management skills, and significant knowledge of and experience with more than one of the following: Employment Practices Liability, Social Service Professional, Sexual Abuse, General Liability, and/ or Automobile or demonstrates expertise in Property claims management as stand alone expertise in the Property area. * Ability and willingness to obtain adjuster licenses as needed in various states. * The incumbent will demonstrate a thorough knowledge of current tort law and case law trends with respect to all casualty lines of business, civil procedure, insurance policy(s) and contract(s). * Must demonstrate good written and oral communication skills. * Must be organized and possess strong follow-up skills. * Requires the ability to analyze and apply creative solutions to claim issues. * Proven critical thinking skills that demonstrate analysis/judgment and sound decision making with focus on attention to details * Strong negotiating skills, excellent telephone, written and verbal communication skills are essential. * Possesses and regularly demonstrates objectivity and pragmatism as well as strong conflict resolution skills * Ability to manage total loss cost outcomes including ALAE to achieve superior results for our members and the company * Incumbent must be aware of and follow guidelines concerning confidentiality. * The position communicates with legal and medical personnel, third party claimants, policyholders, producers, Reinsurers, and senior level staff throughout the company. * Demonstrated capability for working with a high level of independence * Ability to deliver results in a fast-paced environment * Positive approach, can-do attitude, flexibility and ability to operate with grace under pressure * Ability to model and uphold appropriate professional boundaries in work with member-insureds * Collaborate with other staff members and external partners * Interest and commitment to the mission of the organization * Commitment to inspired service * Communicate effectively orally and in writing * While performing the duties of this job, the employee is regularly required to bend, reach or sit for up to 3 hours at a time * Must have adequate vision (with corrective lenses if needed) to clearly view computer screen * Must have adequate hearing to perform job tasks * PC literacy required; proficiency in Windows, Word, and Outlook preferred. * Travel required as necessary and must be able to be productive while traveling on business, including the ability to utilize laptops and other business tools as provided, subject to reasonable accommodation, if needed. * Must have adequate hearing to perform job tasks * If performing as a Property specialist, will be adept at large loss handling techniques, including catastrophe claims. **E****xperience** **•**The position generally requires a minimum of ten or more years of progressively more difficult claims handling experience. **E****du****cation** • Four year college degree or equivalent business experience. ***Compensation:*** *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 location, 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 additional incentive compensation upon achievement of individual and company goals.* **Salary Range** **$69,000 - $146,000**

JOB\_DESCRIPTION.SHARE.HTML CAROUSEL\_PARAGRAPH JOB\_DESCRIPTION.SHARE.HTML * Sunnyvale, California; Los Altos, California; Palo Alto, California * Claims and Investigation * Regular Full Time * 37278 State Farm mail\_outlineGet future jobs matching this search or ** Job Description** **Overview** Build your career at one of the top companies for professional growth in the U.S.! Khakis optional… At State Farm we invest in our employees by providing a competitive Total Rewards package: Starting Salary is $73,824.56 - $114,148.98 annually, $36.64 - $56.65/hour. Because work-life-balance is a priority at State Farm, compensation is based on our standard 38:45-hour work week! Salary offered is dependent on skills and qualifications, with the high end of the range limited to applicants with significant relevant experience. You are also eligible for: * An annual bonus based on individual and enterprise performance potentially up to 15% of annual salary * Annual merit increases * 401(k) contribution * Paid Time Off (PTO), plus: 5 days of Life Leave to take care of yourself and your family, Paid Volunteer Time, and an Annual Celebration Day to celebrate what's important to you! * Industry leading Tuition Assistance Programs * Wellness and mental health programs * Discounts from hundreds of retailers through our Perks at Work program And more! Being good neighbors - helping people, investing in our communities, and making the world a better place - is who we are at State Farm. It is at the core of how we operate and the reason for our success. Come join a #1 team and do some good! **For Los Angeles candidates:** Pursuant to the Los Angeles Fair Chance Initiative for Hiring, we will consider for employment qualified applicants with criminal histories. **For San Francisco candidates:** Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. **Grow Your Skills, Grow Your Potential** **Responsibilities** Join our team as a Property Field Inspection Claim Specialist and showcase your expertise in handling accidental and weather-related claims for homeowners, commercial properties, and large losses. We are looking for an experienced and highly skilled professional to contribute to our dynamic team. You will be the first point of contact to meet with our insureds, explain coverage, estimate damages, and help them through the claims process while providing Remarkable service. Where you'll work: This position is located in **Sunnyvale/Los Altos/Palo Alto/Fremont, CA** and is responsible for servicing these zip codes: **94022, 94024, 94028, 94035, 94040, 94041, 94043, 94085, 94086, 94087, 94089, 94301, 94303, 94304, 94305, 94306, 95002, 95054, 95134.** *Competitive candidates should reside within this zip code territory. Key Responsibilities: * Conduct on-site inspections and assessments of property damages for both residential and commercial claims * Collaborate with policyholders, insurance agents, and other involved parties to gather information and resolve claims efficiently * May occasionally require interacting with parties who express strong emotions or concerns about ongoing inspections or claim resolutions * Provide exceptional customer service throughout the claims process, addressing inquiries and concerns promptly and professionally * Gather necessary evidence, document findings, and prepare detailed reports to support the claims handling process * Investigate and adjust both personal and commercial property claims with exposures up to $500,000 * Evaluate coverage and policy terms to determine the validity of claims and ensure compliance with local regulations * Negotiate and settle claims within the authorized limits, considering policy provisions, industry standards, and company guidelines * Although the primary work location is in the field, with a commutable distance from home, there will be opportunities for virtual work to be completed at home. Additionally, there may be occasions where you will be required to travel to assist in other territories * Hours of operation are continually evaluated and may change based on business need. Successful candidates are able and willing to work flexible schedules and may be asked to work overtime and/or irregular hours. Candidates may be asked to work outside of their assigned territory as business needs dictate **Qualifications** Competitive candidates must demonstrate: * Experience as a Claim Specialist in the insurance industry or other relatable experience * Strong knowledge of property insurance policies, coverage and claim handling practices * Demonstrated knowledge of both residential and commercial building construction * Familiarity with local regulations and compliance requirements in California * Excellent communication and interpersonal skills to effectively interact with clients, agents, and other stakeholders * Proven effective communication skills to handle difficult/emotional conversations with a customer-minded focus * Proven ability to assess damages, estimate repair costs, and negotiate settlements * Detail-oriented with strong organizational and analytical skills * Proficient in using claims management software and other relevant tools Physical Requirements: * Physical agility to allow for: frequent lifting, carrying and climbing a ladder; ability to navigate roofs at various heights for inspection of both residential and commercial structures; ability to crawl in tight spaces * A valid driver's license is required Preferred Skills: * Bachelor's degree in a related field or equivalent work experience * Experience in handling complex or high-value claims * Construction background * Water mitigation inspection * Xactimate, XactContents Employees must successfully complete all required training, including applicable licensing exam(s), MVRs and background checks required of various state(s). Visit for more information on our , , and the . State Farm recently implemented new pre-employment assessments. Candidates that have previously taken an assessment may be asked to participate in additional testing. #LI-DS3 PMCL IN22 We may work with online advertising companies to show you relevant and useful ads including ads displayed on our website and the websites of other companies. These ads may be based on information collected by us or other parties (for example, when you register for a site). These ads may also be based on your activities on our website or on other websites. This is called "online behavioral advertising". Some companies that play a role in the online behavioral advertising process may have sufficient information to identify you. To learn more about online behavioral advertising, visit the Digital Advertising Alliance website.

The preferred candidate will reside in the cities or surrounding areas of Oakland, Hercules, Richmond, Concord, Berkely, Martiez, or Clayton, CA. If you're passionate about helping people restore their lives when the unexpected happens to their homes and providing the best customer experience, then our Mercury Insurance Property Claims team could be the place for you! Upon completion of the training program, ideal candidates will transition into a property claims field adjusting position traveling to loss sites that have been damaged by fire, water, weather, or other unexpected events. You may also handle some claims via virtual technology and/or collaborate with vendors. The Property Claims Field Adjuster ll will learn apply knowledge of current Company policies, applicable regulatory standards, and procedures to investigate, evaluate and settle moderate Homeowner's property claims in a timely and efficient manner as to prevent unnecessary expense to the Company and policyholders, and provide exceptional service to our customers. Responsibilities Essential Job Functions: • Investigate and resolve Homeowners claims of moderate complexity in a timely and efficient manner. Document with photographs, measurements, recorded interviews as needed, write a repair estimate to capture damages, and complete thorough file notes. • Ability to perform field inspections at least 50% of work time. (company car provided) This will involve travelling to our customers' home to conduct on-site inspections, thoroughly investigate coverage and prepare detailed estimate to efficiently resolve their claims. • Ability to handle virtual claims. Must have ability to use imagery, and advanced video technology to collaborate with onsite vendors and insureds to identify damage and write damage estimates from a virtual setting when needed. • Compare facts gathered during the investigation against the policy to determine coverage of claim; extend or deny coverage as appropriate. • Establishes reserve amounts within prescribed settlement authority limit and negotiates settlement of claims; recommends claims which exceed personal authority limit to supervisor for approval. • Responsible for effectively and timely communicating with insureds and /or their representatives to resolve issues and ensure customer satisfaction. This includes timely response to phone calls, emails, texts, written communication, and adherence to Department of Insurance requirements. • Prioritizes own responsibilities and effectively manages claims workload to regularly monitor progress and expenses to properly resolve inventory to conclusion. • At times may direct, monitor, and review files handled by independent adjusters to conclusion. • Other functions may be assigned Qualifications Education: • Bachelor's degree preferred or equivalent combination of education and experience. • Valid driver's license is required. • Ability to obtain state specific property claims licensing, as required. • Must successfully participate and complete formal property claims training program that may take place in person, virtually, or a combination of both. Experience: • Have prior experience using estimating software like Xactimate. • Experience in a related field: property claims experience, customer service environment, construction, restoration, mitigation • Are known for clear and professional communication, both written and verbal • Are bilingual and/or have prior military experience is a plus • 3-5+ years equivalent industry experience is preferred Knowledge and Skills: As a Property Claims Field Adjuster 2, you will: • Possess the ability to work independently with limited or no supervision over daily activities required to successfully investigate, evaluate, write damage estimates, negotiate, and resolve property claims • Have a passion for outstanding customer service • Make quality decisions based upon a mixture of analysis, wisdom, experience, and judgment, including the ability to negotiate. • Be comfortable with and adaptable to new technology and business tools • Be able to seamlessly transition between various methods of inspection, including physical, video, or photo, to write a damage estimate: May include climbing ladders to inspect roofing or attic space and inspection of crawl spaces. Ability to lift and carry up to 50 pounds. • Possess strong organizational, time management, and prioritization skills to handle varying workloads due to seasonal volume changes and catastrophes. • Be able and willing to work flexible work shifts and may be asked to work overtime, as needs arise. • Drive to and from multiple locations and occasionally outside of normal business hours. About the Company Why choose a career at Mercury? At Mercury, we have been guided by our purpose to help people reduce risk and overcome unexpected events for more than 60 years. We are one team with a common goal to help others. Everyone needs insurance and we can't imagine a world without it. Our team will encourage you to grow, make time to have fun, and work together to make great things happen. We embrace the strengths and values of each team member. We believe in having diverse perspectives where everyone is included, to serve customers from all walks of life. We care about our people, and we mean it. We reward our talented professionals with a competitive salary, bonus potential, and a variety of benefits to help our team members reach their health, retirement, and professional goals. Learn more about us here: ********************************************** Perks and Benefits We offer many great benefits, including: Competitive compensation Flexibility to work from anywhere in the United States for most positions Paid time off (vacation time, sick time, 9 paid Company holidays, volunteer hours) Incentive bonus programs (potential for holiday bonus, referral bonus, and performance-based bonus) Medical, dental, vision, life, and pet insurance 401 (k) retirement savings plan with company match Engaging work environment Promotional opportunities Education assistance Professional and personal development opportunities Company recognition program Health and wellbeing resources, including free mental wellbeing therapy/coaching sessions, child and eldercare resources, and more Mercury Insurance is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other characteristic protected by federal, state, or local law. Pay Range USD $73,127.00 - USD $127,722.00 /Yr.

Reporting to the Claims Manager and working independently and with great latitude for independent action, this position manages an inventory consisting primarily of claims with higher loss potential and complexity, and commensurate reserving, settlement authority, reinsurance reporting requirements, as well as claims of lesser exposure or severity as dictated by the needs of the department. Investigates, evaluates and settles claims within designated authority. Occasionally assigns and directs Independent Adjusters/Appraisers and regularly assigns and directs defense attorneys. The ideal candidate would have 10+ years carrier experience and be capable of working independently as well as collaboratively and have prior experience working remotely from a home office. In this position, thorough knowledge and experience is assumed for one or more standard casualty lines, or for demonstrated experience in Property claims. Responsibilities The Claims Examiner IV responsibilities include but are not limited to: Determines coverage(s) applicable to loss. Investigates, manages and resolves claims in a timely, unbiased and informed manner in compliance with company policies, state laws and regulatory performance standards. Sets and maintains adequate claim reserves based on facts of case and in accordance with company policy. Conducts investigation, assigning fieldwork as necessary and appropriate, in accordance with company standards. Determines liability. Evaluates and pays claims within designated authority. When requested, present coverage and claims analysis to management and make recommendations on resolution of disputed items. Set reserves up to the positions level of authority. Prepares and presents verbal and written claim status reports in accordance with company policy and pursuant to Reinsurance treaty requirements. Recommends payment, evaluates and reserves claims and reports to manager cases in excess of designated authority, as well as to Reinsurers pursuant to treaty requirements. Manages legal aspects through timely assignment of litigated cases to defense counsel, and on-going evaluation of legal process and expenses. Maintain electronic files necessary for documentation of the claim file. Analyzes and regularly reports to Claims Manager on the performance of defense counsel. Represents the company at litigation related settlement conferences, mediation, and arbitration when needed. Works closely with outside counsel to monitor claims and work with insureds to resolve underlying litigation Participates in both internal and external audits as needed Participates in weekly department meetings and Claims Committee Meetings as needed Promote the team approach to case and account management. Participates in marketing presentations and training programs as needed. Provide accurate, courteous and timely information to all external and internal customers concerning claims status and other inquiries. Other duties as assigned Required Competencies Requires highly technical claim management skills, and significant knowledge of and experience with more than one of the following: Employment Practices Liability, Social Service Professional, Sexual Abuse, General Liability, and/ or Automobile or demonstrates expertise in Property claims management as stand alone expertise in the Property area. Ability and willingness to obtain adjuster licenses as needed in various states. The incumbent will demonstrate a thorough knowledge of current tort law and case law trends with respect to all casualty lines of business, civil procedure, insurance policy(s) and contract(s). Must demonstrate good written and oral communication skills. Must be organized and possess strong follow-up skills. Requires the ability to analyze and apply creative solutions to claim issues. Proven critical thinking skills that demonstrate analysis/judgment and sound decision making with focus on attention to details Strong negotiating skills, excellent telephone, written and verbal communication skills are essential. Possesses and regularly demonstrates objectivity and pragmatism as well as strong conflict resolution skills Ability to manage total loss cost outcomes including ALAE to achieve superior results for our members and the company Incumbent must be aware of and follow guidelines concerning confidentiality. The position communicates with legal and medical personnel, third party claimants, policyholders, producers, Reinsurers, and senior level staff throughout the company. Demonstrated capability for working with a high level of independence Ability to deliver results in a fast-paced environment Positive approach, can-do attitude, flexibility and ability to operate with grace under pressure Ability to model and uphold appropriate professional boundaries in work with member-insureds Collaborate with other staff members and external partners Interest and commitment to the mission of the organization Commitment to inspired service Communicate effectively orally and in writing While performing the duties of this job, the employee is regularly required to bend, reach or sit for up to 3 hours at a time Must have adequate vision (with corrective lenses if needed) to clearly view computer screen Must have adequate hearing to perform job tasks PC literacy required; proficiency in Windows, Word, and Outlook preferred. Travel required as necessary and must be able to be productive while traveling on business, including the ability to utilize laptops and other business tools as provided, subject to reasonable accommodation, if needed. Must have adequate hearing to perform job tasks If performing as a Property specialist, will be adept at large loss handling techniques, including catastrophe claims. E xperience • The position generally requires a minimum of ten or more years of progressively more difficult claims handling experience. E du cation • Four year college degree or equivalent business experience. Compensation: 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 location, 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 additional incentive compensation upon achievement of individual and company goals. Salary Range $69,000 - $146,000

**Department:** Claims **Office:** Hybrid San Francisco **Salary:** $28 - $32 Reporting to the Manager, Claims, the Claims Examiner is responsible for claims processing, adjudication, and research. You will stay current on claim processing procedures, produce a quality work product, and assist Claims Management with special projects. You will have claims processing experience with the ability to maintain high qualitative and quantitative standards established for this position. Salary: $28.00 - $32.00/hour **WHAT YOU WILL DO:** * The accurate processing, adjudication and claims research to include: + Keep the department's claim inventory current and clear edit queues by process claims according to verification of eligibility, interpretation of program benefits and provider contracts to include manual pricing. + Use the QNXT claims processing module to process claims. + Meet production and quality standards when processing claims and performing tasks. + Handle call tracking tickets promptly regarding claims status, billing and payment issues, disputes, etc. + Stay informed about the changes in Medi-Cal regulations, program policies and current processing procedures. + Foster an environment that solicits and enlists diverse and inclusive perspectives and approaches to better serve our staff, our members and our providers. **WHAT YOU WILL BRING:** * One year prior work experience in medical claims processing preferably with focus on Medi-Cal claims. * Hands-on working knowledge and background using claims processing systems. * Knowledge of CPT/HCPCS, ICD-9 coding, medical terminology and managed care principles. * A high school diploma or equivalent work experience. * Demonstrated working knowledge of editing claims systems such as QNXT. * Experience in Excel, Word, Outlook, and other MS products **WHAT WE OFFER:** * Health Benefits + Medical: You'll have a choice of medical plans, including options from Kaiser and Blue Shield of California, heavily subsidized by SFHP. + Dental: You'll have a choice of a basic dental plan or an enhanced dental plan which includes orthodontic coverage. + Vision: Employee vision care coverage is available through Vision Service Plan (VSP). * Retirement - Employer-matched CalPERS Pension and 401(a) plans, 457 Plan. * Time off - 23 days of Paid Time Off (PTO) and 13 paid holidays. * Professional development: Opportunities for tuition reimbursement, professional license/membership. **ABOUT SFHP:** Established in 1997, San Francisco Health Plan (SFHP) is an award-winning, managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco County. SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 175,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services. San Francisco Health Plan is proud to be an equal opportunity employer. We are committed to a work environment that supports, inspires, and respects all individuals and in which our people processes are applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military service status, citizenship, or other protected characteristics. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. San Francisco Health Plan is an E-Verify participating employer. Hiring priority will be given to candidates residing in the San Francisco Bay Area and California. #LI-Hybrid

Reporting to the Manager, Claims, the Claims Examiner is responsible for claims processing, adjudication, and research. You will stay current on claim processing procedures, produce a quality work product, and assist Claims Management with special projects. You will have claims processing experience with the ability to maintain high qualitative and quantitative standards established for this position. Salary: $28.00 - $32.00/hour WHAT YOU WILL DO: The accurate processing, adjudication and claims research to include: Keep the department s claim inventory current and clear edit queues by process claims according to verification of eligibility, interpretation of program benefits and provider contracts to include manual pricing. Use the QNXT claims processing module to process claims. Meet production and quality standards when processing claims and performing tasks. Handle call tracking tickets promptly regarding claims status, billing and payment issues, disputes, etc. Stay informed about the changes in Medi-Cal regulations, program policies and current processing procedures. Foster an environment that solicits and enlists diverse and inclusive perspectives and approaches to better serve our staff, our members and our providers. WHAT YOU WILL BRING: One year prior work experience in medical claims processing preferably with focus on Medi-Cal claims. Hands-on working knowledge and background using claims processing systems. Knowledge of CPT/HCPCS, ICD-9 coding, medical terminology and managed care principles. A high school diploma or equivalent work experience. Demonstrated working knowledge of editing claims systems such as QNXT. Experience in Excel, Word, Outlook, and other MS products WHAT WE OFFER: Health Benefits Medical: You ll have a choice of medical plans, including options from Kaiser and Blue Shield of California, heavily subsidized by SFHP. Dental: You ll have a choice of a basic dental plan or an enhanced dental plan which includes orthodontic coverage. Vision: Employee vision care coverage is available through Vision Service Plan (VSP). Retirement Employer-matched CalPERS Pension and 401(a) plans, 457 Plan. Time off 23 days of Paid Time Off (PTO) and 13 paid holidays. Professional development: Opportunities for tuition reimbursement, professional license/membership. ABOUT SFHP: Established in 1997, San Francisco Health Plan (SFHP) is an award-winning, managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco County. SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 175,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services. San Francisco Health Plan is proud to be an equal opportunity employer. We are committed to a work environment that supports, inspires, and respects all individuals and in which our people processes are applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military service status, citizenship, or other protected characteristics. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. San Francisco Health Plan is an E-Verify participating employer. Hiring priority will be given to candidates residing in the San Francisco Bay Area and California. #LI-Hybrid

Taking care of people is at the heart of everything we do, and we start by taking care of you, our valued colleague. A career at Sedgwick means experiencing our culture of caring. It means having flexibility and time for all the things that are important to you. It's an opportunity to do something meaningful, each and every day. It's having support for your mental, physical, financial and professional needs. It means sharpening your skills and growing your career. And it means working in an environment that celebrates diversity and is fair and inclusive. A career at Sedgwick is where passion meets purpose to make a positive impact on the world through the people and organizations we serve. If you are someone who is driven to make a difference, who enjoys a challenge and above all, if you're someone who cares, there's a place for you here. Join us and contribute to Sedgwick being a great place to work. Great Place to Work Most Loved Workplace Forbes Best-in-State Employer Claims Examiner - Property/Liab | Public Entity | Field work required | Must reside in Northern California Are you looking for an opportunity to join a global industry leader where you can bring your big ideas to help solve problems for some of the world's best brands? + Apply your examiner knowledge and experience to adjudicate complex customer claims in the context of an energetic culture. + Deliver innovative customer-facing solutions to clients who represent virtually every industry and comprise some of the world's most respected organizations. + Be a part of a rapidly growing, industry-leading global company known for its excellence and customer service. + Leverage Sedgwick's broad, global network of experts to both learn from and to share your insights. + Take advantage of a variety of professional development opportunities that help you perform your best work and grow your career. + Enjoy flexibility and autonomy in your daily work, your location, and your career path. + Access diverse and comprehensive benefits to take care of your mental, physical, financial and professional needs. **ARE YOU AN IDEAL CANDIDATE?** To analyze property & liability public entity claims on behalf of our valued clients to determine benefits due, while ensuring ongoing adjudication of claims within service expectations, industry best practices, and specific client service requirements. **PRIMARY PURPOSE OF THE ROLE:** We are looking for driven individuals that embody our caring counts model and core values that include empathy, accountability, collaboration, growth, and inclusion. **ESSENTIAL RESPONSIBLITIES MAY INCLUDE** + Analyzing and processing claims through well-developed action plans to an appropriate and timely resolution by investigating and gathering information to determine the exposure on the claim. + Negotiating settlement of claims within designated authority. + Communicating claim activity and processing with the claimant and the client. + Reporting claims to the excess carrier and responding to requests of directions in a professional and timely manner. **QUALIFICATIONS** Education & Licensing: 5 years of claims management experience or equivalent combination of education and experience required. + High School Diploma or GED required. Bachelor's degree from an accredited college or university preferred. + Professional certification as applicable to line of business preferred. Licensing / Jurisdiction Knowledge: California - Physical inspections in Northern California **TAKING CARE OF YOU** + Flexible work schedule. + Referral incentive program. + Career development and promotional growth opportunities. + A diverse and comprehensive benefits offering including medical, dental vision, 401K on day one. Work environment requirements for entry-level opportunities include - Physical: Computer keyboarding Auditory/visual: Hearing, vision and talking Mental: Clear and conceptual thinking ability; excellent judgement and discretion; ability to meet deadlines. " _As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is $68-75K_ _. A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits_ ." \#claimsexaminer Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace. **If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.** **Taking care of people is at the heart of everything we do. Caring counts** Sedgwick is a leading global provider of technology-enabled risk, benefits and integrated business solutions. Every day, in every time zone, the most well-known and respected organizations place their trust in us to help their employees regain health and productivity, guide their consumers through the claims process, protect their brand and minimize business interruptions. Our more than 30,000 colleagues across 80 countries embrace our shared purpose and values as they demonstrate what it means to work for an organization committed to doing the right thing - one where caring counts. Watch this video to learn more about us. (************************************** BGSfA)

Job Details Burlingame, CA $36.92 - $41.85 HourlyDescription The MSO Claims Examiner is responsible for the daily review, audit, examination, investigation and adjudication of hospital and professional claims. Must exceed qualitative standard and meet quantitative production standard. Responsible to prepare files and documents for the annual health plan delegation oversight audits, assist Claims Manager with MSO management reports, and other special projects as needed. ESSENTIAL JOB FUNCTIONS: Perform the daily examination, auditing and adjudication activities to submitted hospital and professional claims based on established utilization criteria, Medi-Cal and/or Medicare guidelines, member's Evidence of Benefit, and policies and procedures outlined in the MSO Claims Manual. Responsible for the daily review of complex pre-payment claims reports. Identify processing errors and make corrections prior to the weekly FFS payment cycle. Identify claims payment errors and perform claims revision/correct activities for repayment or deduction per Physician and/or Vendor Contract terms. Must meet quantitative production standard of 425 claims per week. Provides feedback on testing system upgrades and enhancements. Respond to complex provider inquiries related to claims adjudication, denial, and payment status and handle member billed issues when arise. Respond to first level provider inquiries related to claims adjudication, denial, and payment status and handle member billed issues when arise (when necessary). Responsible to prepare, review, and submit claims files and evidence documents for the annual delegation oversight audit(s) performed by Health Plan(s). Provide recommendations to Claims Manager on updating claims policies and procedures to meet turn-around-time and/or CMS/DHCS/MCP regulatory requirement. Assist in training the entry level Claims Examiner for claims auditing and adjudication activities, and other MSO staff with general claims information. Identify system configuration errors and flaws during day-to-day operation, report to department manager and MSO System Configuration team to correct/resolve them. Identify auditing errors and/or training-related opportunities that will improve operational efficiencies and results. Provides information in response to the requests of patient, physician, insurance company or co-worker as appropriate. Prepares and interprets appropriate statistical reports. Performs other job duties as required by manager/supervisor and NEMS Management Team. QUALIFICATIONS: Completion of a 2-year degree from an accredited University, may be substituted with relevant work experience in healthcare medical claims processing and examination field. Minimum 3-4 years of experience in health insurance claims processing, examination, adjudication, and auditing. Strong knowledge of managed care and/or healthcare claim reimbursement or medical billing in Medi-Cal and Medicare Advantage program required. Working knowledge of State/Federal healthcare compliance requirements (HIPAA, AB1455, and ICE standards), particularly DHCS/Medi-Cal and CMS/Medicare guidelines required. Working knowledge of medical terminology, standard code sets including CPT, HCPCS, ICD, POS, and claim forms. Strong English communication skills with strong analytical and problem solving skills. Ability to self-manage in a detail oriented environment. Ability to operate PC based software programs or automated database management systems preferred. Good organization and prioritization skills, outstanding in time management LANGUAGE: Must be able to fluently speak, read and write English. Fluent in other languages are an asset. STATUS: This is an FLSA NON-exempt position. This is not an OSHA high-risk position. This is a Full Time position NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. NEMS BENEFITS: Competitive benefits, including free medical, dental and vision insurance for employee, spouse and/or children; and company contribution to 401(k).

Join our team as a Claims Examiner at Health Plan of San Mateo (HPSM), where you'll play a key role in reviewing and resolving claims for over 160,000 members. In this position, you'll tackle everything from medical and dental claims to inpatient/outpatient, supplies, and DME, all while ensuring they're processed accurately and within established timeframes. You'll research claims, communicate with providers, and resolve issues by making decisions to pay, deny, or adjust claims. Additionally, you'll monitor your productivity, contribute to process improvements, and serve as a subject matter expert for other departments to ensure the highest quality and compliance standards. Key Responsibilities Review and resolve complex claims (medical, dental, inpatient/outpatient, supplies, and DME) for accuracy in a timely manner. Research claims and respond to external inquiries, ensuring accurate information is provided. Resolve claims by paying, denying, adjusting, or escalating as needed, in line with program policies and procedures. Train and audit Claims Examiners I and serve as a subject matter expert for claims-related issues across departments. Monitor personal productivity, suggest improvements for departmental efficiency, and assist in creating process improvements and tools. Requirements These are the qualifications typically needed to succeed in this position. However, you don't need to meet every requirement to apply. Education & Experience: High school diploma, GED, or equivalent required. At least two years of medical and/or dental claims processing experience preferred. Knowledge: Familiarity with Medi-Cal and Medicare benefits, billing requirements, medical terminology, and standard claim forms (CPT, HCPCS, ICD-10 coding). Skills & Abilities: Strong alpha-numeric data entry skills, effective communication abilities (both verbal and written), and the ability to work cooperatively as part of a team. Other Requirements: Ability to organize workflow and adapt quickly to changing departmental priorities while following internal policies and regulatory requirements. Outstanding Benefits Package Includes: 100% HPSM-paid medical, dental, and vision coverage for employees (dependents' premiums are 90% covered by HPSM). Fully funded life insurance, AD&D, and long-term disability (LTD) coverage. Generous retirement plan with HPSM contributing an equivalent to 10% of your annual salary. Ample paid time off: 12 holidays, 12 sick days, and vacation starting at 16 days per year. Tuition reimbursement to support your professional growth. A robust employee wellness program to promote your well-being. It is HPSM's policy to provide equal employment opportunity for all applicants and employees. HPSM does not unlawfully discriminate based on race, religion, color, national origin, ancestry, physical disability, mental disability, medical condition, marital status, sex, age, sexual orientation, veteran status, registered domestic partner status, genetic information, gender, gender identity, gender expression, or any other characteristic protected by applicable federal, state, or local law. HPSM also prohibits discrimination based on the perception that an applicant or employee has any of those characteristics or is associated with a person who has or is perceived to have any of those characteristics. Other details Pay Type Hourly Min Hiring Rate $20.69 Max Hiring Rate $31.66 Job Start Date Tuesday, September 24, 2024

Be Here. Be Great. Working for a leader in the insurance industry means opportunity for you. Great American Insurance Group's member companies are subsidiaries of American Financial Group. We combine a "small company" culture where your ideas will be heard with "big company" expertise to help you succeed. With over 35 specialty property and casualty operations, there are always opportunities here to learn and grow. We value diversity and recognize the benefits gained when people from different cultures, backgrounds and experiences work collaboratively to achieve business results. We are intentionally focused on fostering an inclusive culture and know valuing diversity is an essential leadership quality. Our goal is to create a workplace where all employees feel included, empowered, and enabled to perform at their best. At Republic Indemnity, we've been helping businesses in the western U.S. manage their Workers' Compensation costs for over 50 years. Headquartered in Calabasas, California with additional offices in San Francisco and San Diego, we write workers compensation primarily in CA with significant business in AK, AZ, NV, and other western states. Whether it's helping a broker, policyholder, injured worker, or a colleague, Republic is all about creating a clear way forward so people can reach their goals. If you share that vision, we'd love to talk with you about our exiting opportunity for Workers' Compensation Claims Specialist. This position is based in our San Francisco office with a hybrid schedule of a minimum 1 day in the office per week. Essential Job Functions and Responsibilities Investigates and maintains claims: Reviews and evaluates coverage and/or liability. Secures and analyzes necessary information (i.e., reports, policies, appraisals, releases, statements, records, or other documents) in the investigation of claims. Works toward the resolution of claims files, and attends arbitrations, mediations, depositions or trials as necessary. May affect settlements/reserves within prescribed limits and submit recommendations to supervisor on cases exceeding personal authority. Conveys complex information (coverage, decisions, outcomes, etc.) to all appropriate parties, maintaining a professional demeanor in all situations. Ensures that claims payments are issued in a timely and accurate manner. Ensures that claims handling is conducted in compliance with applicable statutes, regulations and other legal requirements, and that all applicable company procedures and policies are followed. Provides technical advice to lower level positions and other functional areas. May have responsibility for performance and coaching of staff and may have a participatory role in decisions regarding talent selection, development, and performance management for direct reports. Performs other duties as assigned. Job RequirementsEducation: Bachelor's Degree or equivalent experience.Field of Study: Liberal Arts, Business or a related discipline.Experience: Generally, 6 to 10 years of experience handling California Workers' Compensation Claims. Company: RICA Republic Indemnity Company of America Salary Range: $95,000.00 -$112,500.00 Benefits: The wage range for this job is based on role, level, and location. Within the range, individual pay takes into account a variety of factors that are considered in making compensation decisions including but not limited to skills, education, training, licensure and certifications, experience of the candidate, the role's scope, complexity, and other business and organizational needs. In addition to the base compensation, we offer a competitive Total Rewards package, which includes but is not limited to medical, dental, vision, paid time off, and 401(k) plan for full-time and part-time employees who are eligible for benefits. Your recruiter may be able to tell you more about our total rewards offerings and the specific wage range for the relevant location(s) during the hiring process.

You have a clear vision of where your career can go. And we have the leadership to help you get there. At CNA, we strive to create a culture in which people know they matter and are part of something important, ensuring the abilities of all employees are used to their fullest potential. This individual contributor position works under moderate direction, and within defined authority limits, to manage commercial claims with moderate to high complexity and exposure for a specific line of business. Responsibilities include investigating and resolving claims according to company protocols, quality and customer service standards. Position requires regular communication with customers and insureds and may be dedicated to specific account(s). JOB DESCRIPTION: Essential Duties & Responsibilities: Performs a combination of duties in accordance with departmental guidelines: * Manages an inventory of moderate to high complexity and exposure commercial claims by following company protocols to verify policy coverage, conduct investigations, develop and employ resolution strategies, and authorize disbursements within authority limits. * Provides exceptional customer service by interacting professionally and effectively with insureds, claimants and business partners, achieving quality and cycle time standards, providing regular, timely updates and responding promptly to inquiries and requests for information. * Verifies coverage and establishes timely and adequate reserves by reviewing and interpreting policy language and partnering with coverage counsel on more complex matters , estimating potential claim valuation, and following company's claim handling protocols. * Conducts focused investigation to determine compensability, liability and covered damages by gathering pertinent information, such as contracts or other documents, taking recorded statements from customers, claimants, injured workers, witnesses, and working with experts, or other parties, as necessary to verify the facts of the claim. * Establishes and maintains working relationships with appropriate internal and external work partners, suppliers and experts by identifying and collaborating with resources that are needed to effectively resolve claims. * Authorizes and ensures claim disbursements within authority limit by determining liability and compensability of the claim, negotiating settlements and escalating to manager as appropriate. * Contributes to expense management by timely and accurately resolving claims, selecting and actively overseeing appropriate resources, and delivering high quality service. * Identifies and addresses subrogation/salvage opportunities or potential fraud occurrences by evaluating the facts of the claim and making referrals to appropriate Recovery or SIU resources for further investigation. * Achieves quality standards on every file by following all company guidelines, achieving quality and cycle time targets, ensuring proper documentation and issuing appropriate claim disbursements. * Maintains compliance with state/local regulatory requirements by following company guidelines, and staying current on commercial insurance laws, regulations or trends for line of business. * May serve as a mentor/coach to less experienced claim professionals May perform additional duties as assigned. Reporting Relationship Typically Manager or above Skills, Knowledge & Abilities * Solid working knowledge of the commercial insurance industry, products, policy language, coverage, and claim practices. * Solid verbal and written communication skills with the ability to develop positive working relationships, summarize and present information to customers, claimants and senior management as needed. * Demonstrated ability to develop collaborative business relationships with internal and external work partners. * Ability to exercise independent judgement, solve moderately complex problems and make sound business decisions. * Demonstrated investigative experience with an analytical mindset and critical thinking skills. * Strong work ethic, with demonstrated time management and organizational skills. * Demonstrated ability to manage multiple priorities in a fast-paced, collaborative environment at high levels of productivity. * Developing ability to negotiate low to moderately complex settlements. * Adaptable to a changing environment. * Knowledge of Microsoft Office Suite and ability to learn business-related software. * Demonstrated ability to value diverse opinions and ideas Education & Experience: * Bachelor's Degree or equivalent experience. * Typically a minimum four years of relevant experience, preferably in claim handling. * Candidates who have successfully completed the CNA Claim Training Program may be considered after 2 years of claim handling experience. * Must have or be able to obtain and maintain an Insurance Adjuster License within 90 days of hire, where applicable. * Professional designations are a plus (e.g. CPCU) #LI-AR1 #LI-Hybrid In certain jurisdictions, CNA is legally required to include a reasonable estimate of the compensation for this role. In District of Columbia, California, Colorado, Connecticut, Illinois, Maryland, Massachusetts, New York and Washington, the national base pay range for this job level is $54,000 to $103,000 annually. Salary determinations are based on various factors, including but not limited to, relevant work experience, skills, certifications and location. CNA offers a comprehensive and competitive benefits package to help our employees - and their family members - achieve their physical, financial, emotional and social wellbeing goals. For a detailed look at CNA's benefits, please visit cnabenefits.com. CNA is committed to providing reasonable accommodations to qualified individuals with disabilities in the recruitment process. To request an accommodation, please contact ***************************.

You have a clear vision of where your career can go. And we have the leadership to help you get there. At CNA, we strive to create a culture in which people know they matter and are part of something important, ensuring the abilities of all employees are used to their fullest potential. This individual contributor position works under moderate direction, and within defined authority limits, to manage commercial claims with moderate to high complexity and exposure for a specific line of business. Responsibilities include investigating and resolving claims according to company protocols, quality and customer service standards. Position requires regular communication with customers and insureds and may be dedicated to specific account(s). JOB DESCRIPTION: Essential Duties & Responsibilities: Performs a combination of duties in accordance with departmental guidelines: Manages an inventory of moderate to high complexity and exposure commercial claims by following company protocols to verify policy coverage, conduct investigations, develop and employ resolution strategies, and authorize disbursements within authority limits. Provides exceptional customer service by interacting professionally and effectively with insureds, claimants and business partners, achieving quality and cycle time standards, providing regular, timely updates and responding promptly to inquiries and requests for information. Verifies coverage and establishes timely and adequate reserves by reviewing and interpreting policy language and partnering with coverage counsel on more complex matters , estimating potential claim valuation, and following company's claim handling protocols. Conducts focused investigation to determine compensability, liability and covered damages by gathering pertinent information, such as contracts or other documents, taking recorded statements from customers, claimants, injured workers, witnesses, and working with experts, or other parties, as necessary to verify the facts of the claim. Establishes and maintains working relationships with appropriate internal and external work partners, suppliers and experts by identifying and collaborating with resources that are needed to effectively resolve claims. Authorizes and ensures claim disbursements within authority limit by determining liability and compensability of the claim, negotiating settlements and escalating to manager as appropriate. Contributes to expense management by timely and accurately resolving claims, selecting and actively overseeing appropriate resources, and delivering high quality service. Identifies and addresses subrogation/salvage opportunities or potential fraud occurrences by evaluating the facts of the claim and making referrals to appropriate Recovery or SIU resources for further investigation. Achieves quality standards on every file by following all company guidelines, achieving quality and cycle time targets, ensuring proper documentation and issuing appropriate claim disbursements. Maintains compliance with state/local regulatory requirements by following company guidelines, and staying current on commercial insurance laws, regulations or trends for line of business. May serve as a mentor/coach to less experienced claim professionals May perform additional duties as assigned. Reporting Relationship Typically Manager or above Skills, Knowledge & Abilities Solid working knowledge of the commercial insurance industry, products, policy language, coverage, and claim practices. Solid verbal and written communication skills with the ability to develop positive working relationships, summarize and present information to customers, claimants and senior management as needed. Demonstrated ability to develop collaborative business relationships with internal and external work partners. Ability to exercise independent judgement, solve moderately complex problems and make sound business decisions. Demonstrated investigative experience with an analytical mindset and critical thinking skills. Strong work ethic, with demonstrated time management and organizational skills. Demonstrated ability to manage multiple priorities in a fast-paced, collaborative environment at high levels of productivity. Developing ability to negotiate low to moderately complex settlements. Adaptable to a changing environment. Knowledge of Microsoft Office Suite and ability to learn business-related software. Demonstrated ability to value diverse opinions and ideas Education & Experience: Bachelor's Degree or equivalent experience. Typically a minimum four years of relevant experience, preferably in claim handling. Candidates who have successfully completed the CNA Claim Training Program may be considered after 2 years of claim handling experience. Must have or be able to obtain and maintain an Insurance Adjuster License within 90 days of hire, where applicable. Professional designations are a plus (e.g. CPCU) #LI-AR1 #LI-Hybrid In certain jurisdictions, CNA is legally required to include a reasonable estimate of the compensation for this role. In District of Columbia, California, Colorado, Connecticut, Illinois , Maryland, Massachusetts , New York and Washington, the national base pay range for this job level is $54,000 to $103,000 annually. Salary determinations are based on various factors, including but not limited to, relevant work experience, skills, certifications and location. CNA offers a comprehensive and competitive benefits package to help our employees - and their family members - achieve their physical, financial, emotional and social wellbeing goals. For a detailed look at CNA's benefits, please visit cnabenefits.com. CNA is committed to providing reasonable accommodations to qualified individuals with disabilities in the recruitment process. To request an accommodation, please contact ***************************.

The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. We are hiring a Claims Processor to join our team! . Our Vision: Continuously improve the health of our community. Our Mission: We provide healthcare value and advance wellness through community partnerships. What You Will Be Doing: Under direct supervision, responsible for researching and resolving claims pended by HPSJ's claim system to facilitate and complete successful, accurate and timely adjudication. Essential Functions: Reviews claims data for accuracy and completeness. Researches and analyzes issues and errors to correctly identify cause. Approves or denies claims and sends required correspondence based on processing guidelines and production standards. Identifies error patterns and trends; documents and escalates. What You Bring: Ability to understand and apply moderately complex documents, and oral and written instructions. Ability to compare and discern the difference between multiple sets of data or information. Basic problem solving and analytical skills, including the ability to perform routine analysis and resolve problems using identified data and information. Produces work that is accurate and complete. Produces the appropriate amount of work. Actively learns through experimentation when tackling new problems, using both successes and failures to learn. Rebounds from setbacks and adversity when facing difficult situations. Knows the most effective and efficient process to get things done, with a focus on continuous improvement. Interpersonal skills - interacts effectively with individuals both inside and outside of HPSJ; relates openly and comfortably with diverse groups of people. Strong oral and written communication skills, with ability to express self clearly and professionally, with appropriate grammar and spelling, and document according to standards. Ability to work independently and as part of a team. Demonstrates a commitment to HPSJ's strategy, vision, mission and values. Time management and organizational skills. Uses time effectively and efficiently. Values time. Concentrates his/her efforts on the more important priorities. Can attend to a broader range of activities. Meets deadlines. Basic arithmetic skills. Basic skills in Windows, Excel, Word and Outlook. Ability to treat confidential information with appropriate discretion. Ability to speak and be understood in English. Preferred Basic knowledge of and skills in automated claims processing systems. Basic knowledge of regulations governing Medi-Cal and/or managed care as they relate to claims. Basic knowledge of procedure coding and medical terminology, and their application in claims. Basic knowledge of general medical policy benefits and exclusions. Basic knowledge of industry standard payment practices. What You Have: High school diploma or general education degree; and At least two years of general clerical or data entry experience. Preferred Claims or billing experience in healthcare, Medi-Cal and/or managed care. What You Will Get: HPSJ Perks: Competitive salary Robust and affordable health/dental/vision (90% paid medical for employees and 100% paid dental/vision for employees) with choices in providers Generous paid time off (starting at 3 weeks of PTO, 4 paid floating holidays including employee's birthday, and 9 paid holidays) CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan Two flexible spending accounts (FSAs) Employer-Paid Term Life and AD&D Insurance Employer-Paid Disability Insurance Employer-Paid Life Assistance Program

HealthCare Support Staffing, Inc. (HSS), is a proven industry-leading national healthcare recruiting and staffing firm. HSS has a proven history of placing talented healthcare professionals in clinical and non-clinical positions with some of the largest and most prestigious healthcare facilities including: Fortune 100 Health Plans, Mail Order Pharmacies, Medical Billing Centers, Hospitals, Laboratories, Surgery Centers, Private Practices, and many other healthcare facilities throughout the United States. HealthCare Support Staffing maintains strong relationships with top providers in healthcare and can assure healthcare professionals they will receive fast access to great career opportunities that best fit their expertise. Connect with one of our Professional Recruiting Consultants today to see how a conversation can turn into a long-lasting and rewarding career! Are you an experienced Claims Specialist looking for a new opportunity with a prestigious healthcare company? Do you want the chance to advance your career by joining a rapidly growing company? If you answered “yes" to any of these questions - this is the position for you! Company Job Description/Essential Functions: Review and process provider dispute resolutions according to state and federally defined timeframes. Research issues; adjust claims, including computation of interest owed as appropriate. Send written responses to providers in a professional manner within required timelines. Forward cases to the IRE or the DMHC as needed. Answer provider inquiries regarding disputes that have been submitted. Maintain and track disputes through HPSM's grievance and appeals database. Maintain knowledge of claims procedures and all appropriate reference materials; participate in ongoing training as needed. Qualifications 2+ years' experience working with medical claims (Example: Claims Examiner, Claims Provider Services Rep) Must have experience in a health services and/or managed care setting Medi-Cal & Medicare program knowledge Must be well-versed in medical claims and reimbursement process Experience with Microsoft Office software Additional Information Advantages of this Opportunity: • Hours for this Position: Monday- Friday 8:00am to 5:00pm • Pay up to $22 per hour, negotiable • Immediate opening, Temp-to-Perm position with excellent benefits offered. If you know of someone looking for a new opportunity, please pass along the information! We offer referral bonuses of up to $100.00 for each placement.

JOB\_DESCRIPTION.SHARE.HTML CAROUSEL\_PARAGRAPH JOB\_DESCRIPTION.SHARE.HTML * Millbrae, California * Claims and Investigation * Regular Full Time * 36365 mail\_outlineGet future jobs matching this search or ** Job Description** Build your career at one of the top companies for professional growth in the U.S.! Khakis optional… At State Farm we invest in our employees by providing a competitive Total Rewards package: Starting Salary is $68,787.06 - $114,148.98 annually, $34.14 - $56.65/hour. Because work-life-balance is a priority at State Farm, compensation is based on our standard 38:45-hour work week! Salary offered is dependent on skills and qualifications, with the high end of the range limited to applicants with significant relevant experience. You are also eligible for: * An annual bonus based on individual and enterprise performance * Annual merit increases * 401(k) contribution * Paid Time Off (PTO), plus: 5 days of Life Leave to take care of yourself and your family, Paid Volunteer Time, and an Annual Celebration Day to celebrate what's important to you! * Industry leading Tuition Assistance Programs * Wellness and mental health programs * Discounts from hundreds of retailers through our Perks at Work program And more! Being good neighbors - helping people, investing in our communities, and making the world a better place - is who we are at State Farm. It is at the core of how we operate and the reason for our success. Come join a #1 team and do some good! **For Los Angeles candidates:** Pursuant to the Los Angeles Fair Chance Initiative for Hiring, we will consider for employment qualified applicants with criminal histories. **For San Francisco candidates:** Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. **Grow Your Skills, Grow Your Potential** **Responsibilities** Join our team as a Property Field Inspection Claim Specialist and showcase your expertise in handling accidental and weather-related claims for homeowners, commercial properties, and large losses. We are looking for an experienced and highly skilled professional to contribute to our dynamic team. You will be the first point of contact to meet with our insureds, explain coverage, estimate damages, and help them through the claims process while providing Remarkable service. Where you'll work: This position is located in **Millbrae, CA** and is responsible for servicing these zip codes: 94005, 94010, 94014, 94015, 94019, 94030, 94037, 94038, 94044, 94066, 94080, 94112, 94128, 94401. *Competitive candidates should reside within this zip code territory. Key Responsibilities: * Conduct on-site inspections and assessments of property damages for both residential and commercial claims * Collaborate with policyholders, insurance agents, and other involved parties to gather information and resolve claims efficiently * May occasionally require interacting with parties who express strong emotions or concerns about ongoing inspections or claim resolutions * Provide exceptional customer service throughout the claims process, addressing inquiries and concerns promptly and professionally * Gather necessary evidence, document findings, and prepare detailed reports to support the claims handling process * Investigate and adjust both personal and commercial property claims with exposures up to $500,000 * Evaluate coverage and policy terms to determine the validity of claims and ensure compliance with local regulations * Negotiate and settle claims within the authorized limits, considering policy provisions, industry standards, and company guidelines * Although the primary work location is in the field, with a commutable distance from home, there will be opportunities for virtual work to be completed at home. Additionally, there may be occasions where you will be required to travel to assist in other territories * Hours of operation are continually evaluated and may change based on business need. Successful candidates are able and willing to work flexible schedules and may be asked to work overtime and/or irregular hours. Candidates may be asked to work outside of their assigned territory as business needs dictate **Qualifications** * Bachelor's degree in a related field is preferred or equivalent work experience * Minimum of 5 years of experience as a Property Field Inspection Claim Specialist in the insurance industry, specifically in property claims * Strong knowledge of property insurance policies, coverage and claim handling practices * Demonstrated knowledge of both residential and commercial building construction * Familiarity with local regulations and compliance requirements in California * Excellent communication and interpersonal skills to effectively interact with clients, agents, and other stakeholders * Proven effective communication skills to handle difficult/emotional conversations with a customer-minded focus * Proven ability to assess damages, estimate repair costs, and negotiate settlements * Detail-oriented with strong organizational and analytical skills * Proficient in using claims management software and other relevant tools Physical Requirements: * Physical agility to allow for: frequent lifting, carrying and climbing a ladder; ability to navigate roofs at various heights for inspection of both residential and commercial structures; ability to crawl in tight spaces * A valid driver's license is required Preferred Skills: * Experience in handling complex or high-value claims * Construction background * Water mitigation inspection * Xactimate, XactContents Employees must successfully complete all required training, including applicable licensing exam(s), MVRs and background checks required of various state(s). Visit for more information on our , , and the . State Farm recently implemented new pre-employment assessments. Candidates that have previously taken an assessment may be asked to participate in additional testing. #LI-DS3 PMCL IN22 We may work with online advertising companies to show you relevant and useful ads including ads displayed on our website and the websites of other companies. These ads may be based on information collected by us or other parties (for example, when you register for a site). These ads may also be based on your activities on our website or on other websites. This is called "online behavioral advertising". Some companies that play a role in the online behavioral advertising process may have sufficient information to identify you. To learn more about online behavioral advertising, visit the Digital Advertising Alliance website.

Reporting to the Manager, Claims, the Claims Examiner is responsible for claims processing, adjudication, and research. You will stay current on claim processing procedures, produce a quality work product, and assist Claims Management with special projects. You will have claims processing experience with the ability to maintain high qualitative and quantitative standards established for this position. Salary: $28.00 - $32.00/hour WHAT YOU WILL DO: * The accurate processing, adjudication and claims research to include: * Keep the departments claim inventory current and clear edit queues by process claims according to verification of eligibility, interpretation of program benefits and provider contracts to include manual pricing. * Use the QNXT claims processing module to process claims. * Meet production and quality standards when processing claims and performing tasks. * Handle call tracking tickets promptly regarding claims status, billing and payment issues, disputes, etc. * Stay informed about the changes in Medi-Cal regulations, program policies and current processing procedures. * Foster an environment that solicits and enlists diverse and inclusive perspectives and approaches to better serve our staff, our members and our providers. WHAT YOU WILL BRING: * One year prior work experience in medical claims processing preferably with focus on Medi-Cal claims. * Hands-on working knowledge and background using claims processing systems. * Knowledge of CPT/HCPCS, ICD-9 coding, medical terminology and managed care principles. * A high school diploma or equivalent work experience. * Demonstrated working knowledge of editing claims systems such as QNXT. * Experience in Excel, Word, Outlook, and other MS products WHAT WE OFFER: * Health Benefits * Medical: Youll have a choice of medical plans, including options from Kaiser and Blue Shield of California, heavily subsidized by SFHP. * Dental: Youll have a choice of a basic dental plan or an enhanced dental plan which includes orthodontic coverage. * Vision: Employee vision care coverage is available through Vision Service Plan (VSP). * Retirement Employer-matched CalPERS Pension and 401(a) plans, 457 Plan. * Time off 23 days of Paid Time Off (PTO) and 13 paid holidays. * Professional development: Opportunities for tuition reimbursement, professional license/membership. ABOUT SFHP: Established in 1997, San Francisco Health Plan (SFHP) is an award-winning, managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco County. SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 175,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services. San Francisco Health Plan is proud to be an equal opportunity employer. We are committed to a work environment that supports, inspires, and respects all individuals and in which our people processes are applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military service status, citizenship, or other protected characteristics. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. San Francisco Health Plan is an E-Verify participating employer. Hiring priority will be given to candidates residing in the San Francisco Bay Area and California. #LI-Hybrid