Claim processor jobs in Maine - 29 jobs

At OneAmerica, we deliver on promises when customers need us most. We believe the best way to serve our customers is to know that every individual, employee, family and business we work with has unique personal and financial goals. We keep our promises, so we can help them achieve their goals and realize their definition of financial success. Job Summary The STD Claims Examiner is responsible for contributing to the overall success of OneAmerica objectives by providing timely and accurate support to our client companies and the Claims department. This individual will be responsible for managing appropriate adjudication of short-term disability claims in accordance with policy provisions. The STD Claims Examiner will initiate and facilitate case management as well as other ancillary services to assure optimum outcomes. We are currently seeking Level I & II Representative experience. KEY RESPONSIBILITIES: * Promote a positive customer service image through prompt, accurate and courteous responses to customer information needs * Consistently adhere to the documented workflow guidelines and established procedures. * Maintain required levels of confidentiality * Demonstrate competency in all modules of training program. Remain abreast of industry standards via internal/external continuing education * Promptly and thoroughly investigate and evaluate claims within departmental and regulatory guidelines * Interpret and administer contract provisions including, but not limited to, eligibility, covered weekly earnings, definition of Total Disability, verification of applicable offsets and pre-existing investigations * Calculate benefit and identify other income replacement benefits. Processes financial activities, including, but not limited to, payment adjustments, stop payments, voids and check reissues, other income adjustments, reimbursement checks, and final benefits. Processes overpayments in accordance with established procedures * Assist in the subrogation process to recover money from third parties * Work in coordination with an LTD Examiner to ensure an appropriate transition from the STD claim to LTD * Document claim file actions and telephone conversations appropriately * Refer claim activity outside authority level to Supervisor/Manager for review * Proactively communicate with claimants, policyholders and physicians to resolve investigations issues * Establish, communicate and manage claimant and policyholder expectations * Utilize most efficient means to obtain claim information * Fully investigates all relevant claim issues, provides payment or denials promptly and in full compliance with departmental procedures and Unfair Claims Practice regulations * Respond to customer service issues within required timeframes * Involve technical resources (Social Security Specialist, medical resources and vocational resources) at appropriate claim junctures * Support relationships with technical resources to achieve appropriate outcomes * Meet or exceed departmental service, quality and production objectives * Collaborate with team members and management in identifying and implementing improvement opportunities. Informs Supervisor of any trends noted within specific client companies * All other duties as assigned REQUIREMENTS: * BA/BS or equivalent combination of education and experience * 0-2+ years of experience in managing Short Term Disability claims with first pay authority * Ability to fluently speak and write Spanish a plus * Excellent customer service skills * Excellent math and calculation skills * Good decision-making skills * Ability to analyze complex claim information * Working knowledge of Microsoft Excel and Word * High School Diploma required, or any combination of education and experience which would provide an equivalent background. Salary Band: 3C #LI-SC1 This selected candidate will be expected to work hybrid in Portland, ME. The candidate will also be expected to physically return to the office in CA, IN or ME as business needs dictate or for team-building and collaboration. If you are offered and accept this position, please be advised that OneAmerica Financial does not have any offices located in the State of New York and OneAmerica Financial associates are not permitted to work remotely in the State of New York. Disclaimer: OneAmerica Financial is an equal opportunity employer and strictly prohibits unlawful discrimination based upon an individual's race, color, religion, gender, sexual orientation, gender identity/expression, national origin/ancestry, age, mental/physical disability, medical condition, marital status, veteran status, or any other characteristic protected by law. For all positions: Because this position is regulated by the Violent Crime Control and Law Enforcement Act, if an offer is made, applicants must undergo mandated background checks as a condition of employment. Such background checks include criminal history. A conviction is not necessarily an absolute bar to employment. Consistent with applicable regulatory guidelines and law, factors such as the age of the offense, evidence of rehabilitation, seriousness of violation, and job relatedness are considered. To learn more about our products, services, and the companies of OneAmerica Financial, visit oneamerica.com/companies.

Job Responsibilities and Requirements Obtains and analyzes information to make claim decisions and payments of Short Term Disability (STD) claims. The goal of the position/role is to consistently pay the accurate amount for each claim in accordance with the contract. Research Applies knowledge of disability products, policies and contracts. Interprets and applies contract/policy definitions of disability and relevant provisions, clauses, exclusions, riders and waivers as well as statutory requirements. Utilizes reference materials and tools regarding medical, vocational and disability issues to identify and evaluate claim information in a fair and objective manner. Efficient use of applicable disability claims system(s). Applies routine medical and technical claims skills, practices, and procedures. Utilizes most efficient means to obtain claim information. Analysis and Adjudication Fully investigates all relevant claim issues. Provides payment or denials promptly and in full compliance with department procedures and regulations. Involves technical resources (Social Security specialist, medical resources, and vocational resources) at appropriate claim junctures. Determine and implement appropriate return to work strategy for assigned cases. Applies contract specifics regarding eligibility and pre-existing formulas in reference to specific claim. Communicates with claimants, policyholders, and physicians to resolve investigations concerns. Comfortably makes balanced decisions in situations where there are potential adverse consequences. Case Management Utilizes appropriate intervention for the characteristics of each claim. Manages assigned case load of 100-110 complex and some simple cases independently. Collaborates with team members and management in identifying and implementing improvement opportunities. Manages appropriate volumes, consistently meeting turnaround times, high activity levels, and quality focus on timely claim activities. Consistently remain within workflow guidelines on diaries and casework & adjust desk management if needed. Provides clear, concise and accurate information to claimants as well as the claims administrative system. Serves as a subject matter expert within team, provides some mentor support for newer examiners to assist in their development. Customer Service Provide customer service that is respectful, prompt, concise, and accurate in an environment with competing demands. Establishes, communicates, and manages claimant and policyholder expectations. Documents claim file actions and telephone conversations appropriately. Required Competencies 2 years STD claims examiner experience (Short Term Disability) Associates Degree, Bachelors Preferred Promptly acknowledges customers' needs, both internal and external. Ensures customers' needs are handled in a timely and appropriate manner. Creates a positive impression. Demonstrates effective interpersonal and listening skills: takes direction, practices active listening, accepts feedback. Communicate/respond appropriately to varied audiences/tasks. Exhibits teamwork, honors commitments. Anticipates, analyzes and defines problems. Develops and assesses alternative solutions as necessary. Makes appropriate decisions in a timely manner. Analyzes impact of decisions. Work is accomplished quickly and accurately. Takes responsibility for actions. Prioritizes work effectively and uses time efficiently. Accomplishes goals and objectives. Makes/fulfills commitments. Consistently works independently, meets deadlines, and accepts responsibility for his/her actions. Adheres to all attendance requirements. Prompt, well prepared and ready to contribute. Level I LOMA Designation Preferred Ability to Travel: None The expected hiring range for this position is $23.24 - $29.04 hourly for work performed in the primary location (South Portland, ME). This expected hiring range covers only base pay and excludes any other compensation components such as commissions or incentive awards. The successful candidate's starting base pay will be based on several factors including work location, job-related skills, experience, qualifications, and market conditions. These ranges may be modified in the future. Work location may be flexible if approved by the Company. What We Offer At Reliance Matrix, we believe that fostering an inclusive culture allows us to realize more of our potential. And we can't do this without our most important asset-you. That is why we offer a competitive pay package and a range of benefits to help team members thrive in their financial, physical, and mental wellbeing. Our Benefits: An annual performance bonus for all team members Generous 401(k) company match that is immediately vested A choice of three medical plans (that include prescription drug coverage) to suit your unique needs. For High Deductible Health Plan enrollees, a company contribution to your Health Savings Account Multiple options for dental and vision coverage Company provided Life & Disability Insurance to ensure financial protection when you need it most Family friendly benefits including Paid Parental Leave & Adoption Assistance Hybrid work arrangements for eligible roles Tuition Reimbursement and Continuing Professional Education Paid Time Off - new hires start with at least 20 days of PTO per year in addition to nine company paid holidays. As you grow with us, your PTO may increase based on your level within the company and years of service. Volunteer days, community partnerships, and Employee Assistance Program Ability to connect with colleagues around the country through our Employee Resource Group program Our Values: Integrity Empowerment Compassion Collaboration Fun EEO Statement Reliance Matrix is an equal opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, national origin, citizenship, age or disability, or any other classification or characteristic protected by federal or state law or regulation. We assure you that your opportunity for employment depends solely on your qualifications. #LI-Remote #LI-MR1

Job Responsibilities and Requirements KEY RESPONSIBILITIES *other duties as assigned* Responsible for supporting both the supervisor and examiners in the day-to-day operation of the claim team. The Claims Team Lead will also be responsible for developing and sustaining excellent internal partnerships with other areas in the company. In addition, the Claims Team Lead will act as an examiner when needed to balance workloads. In this role, they would be accountable for the decision making process for determining eligibility under federal, state laws and client policy. Secure and analyze information to make and approve decisions on all short-term disability, insured or self-insured, and/or statutory claims and their concurrent leave claims. Develop and apply appropriate claim and workflow management strategies, coordinating both disability and leave decisions while meeting timeliness regulations. Duties and Responsibilities: Supports the achievement of established departmental goals and objectives related to all claim operations in compliance with the Claim Organization's standards Supports both the supervisor for team leadership, as well as the individual examiners to provide day-to-day guidance and workload balancing. Partners with Claim Operations leaders to review specific claims that fall within defined parameters to better understand claim trends, training opportunities, coaching opportunities, and/or performance management opportunities. Supports all training and coaching activities through communications via phone, email and video follow-up with examiners/supervisors. Develops and maintains strong working relationships with business partners. Reviews claims to ensure that decisions related to eligibility, disability, offsets, benefit calculations and ongoing claim management are accurate and appropriate. Ensures achievement of specific customer service, quality and production objectives. Ensures claim process consistency through continuous communication and feedback with the examiners/supervisor. Responsible for assisting in reviewing and completing monthly reports Ability to interact and respond to both internal and external customers regarding claim results. Ability to prioritize and manage changing workloads, meeting deadlines independently and through management of others. Ability and knowledge to assist with claim denial reviews. Ability to assist in claim auditing. Completion of Mentor Training and successful completion of one year of mentoring. Collaborates with team members and management in identify and implementing improvement opportunities. Ability to participate in finalist presentations and ongoing client meetings. Ability to review audit findings and prepare rebuttals. Ability to back up supervisor in periods of extended absences or vacations Ability to back up examiners in periods of high volume or extended absences/vacations with the following duties and responsibilities: Responds to customer service issues within required timeframes. Pro-actively communicates decisions within Best Practice guidelines, consistently meeting Performance Guarantee requirements. Determining eligibility under federal and state requirements for leaves submitted and determines eligibility under client's plan/policy. Medical certification review and management supplied by the healthcare provider. Makes determinations to approve, deny or delay and or reach out to additional resources for review. Determining the duration associated with the leave and or disability based on the information given by the healthcare provider. Communicating approvals, denials, leave extensions, return to work plans and other important information regarding the leave to the employee and client. Managing leaves that are concurrent with Short Term Disability and Workers' Compensation. Managing intermittent, continuous and client specific leaves of absences. Processing all leaves within the specific timeframes outlined within Matrix Best Practices guidelines. Facilitate issue resolution and draw on expertise of internal partners as needed. Ability to interpret and administer policy/plan provisions Fully Investigates all relevant issues, providers, payment or denials, promptly and in full compliance with departmental procedures and unfair claims practice and regulations. Manages self-insured business in accordance with client's plans and custom requirements. Basic knowledge of ERISA. Ability to calculate earnings and benefit levels. Document claim file actions and conversations thoroughly. Fully Investigates all relevant issues, providers, payments. Demonstrates ability to independently investigate, evaluate and adjudicate claims of high degree of complexity. Any other job-related duty as deemed appropriate by management REQUIRED KNOWLEDGE, SKILLS, ABILITIES, COMPETENCIES, AND/OR RELATED EXPERIENCE *or equivalent experience gained from any combination of formal education, on-the-job training, and/or work and life experience* Required Knowledge, Skills, Abilities and/or Related Experience Associate's Degree or equivalent required. Bachelor's Degree preferred. Completion of HIAA, LOMA or ICA courses desirable. Minimum of 5 years relevant experience Demonstrated ability to handle multiple competing priorities. Demonstrated ability to provide feedback on Claims handling Demonstrated ability to function with limited supervision. Demonstrated ability to work well in a high visibility environment, with excellent written and verbal communication skills. Ability to Travel: Up to 10% PHYSICAL REQUIREMENTS When used in the description below, the following terms are defined as: “Occasional”: done only from time to time, but necessary when it is performed “Frequent”: regularly performed; generally an act that is required on a daily basis “Continuous”: typically performed for the majority of an employee's shift Sitting for prolonged periods of time, frequently standing, walking distances up to one mile, bending, crouching, kneeling, reaching, occasionally lifting 25lbs, extensive typing, picking up and holding small objecting and otherwise using primarily the fingers rather than the entire hand. Employee is required to have visual acuity sufficient to perform activities such as preparing and analyzing data and figures; transcribing notes; viewing a computer terminal and extensive reading. Employee is required to have hearing sufficient to understand verbal instruction and answer telephones. Reliance Matrix will provide qualified employees with a reasonable accommodation in accordance with applicable law. CORE VALUES Collaboration Compassion Empowerment Integrity Fun The above description reflects the general details considered necessary to describe the principle responsibilities and functions of the job identified and shall not be construed as a detailed description of all the work requirements that may be inherent to this job. The expected hiring range for this position is $63,540.00 - $85,800.00 annually. This expected hiring range covers only base pay and excludes any other compensation components such as commissions or incentive awards. The successful candidate's starting base pay will be based on several factors including work location, job-related skills, experience, qualifications, and market conditions. These ranges may be modified in the future. Work location may be flexible if approved by the Company. What We Offer At Reliance Matrix, we believe that fostering an inclusive culture allows us to realize more of our potential. And we can't do this without our most important asset-you. That is why we offer a competitive pay package and a range of benefits to help team members thrive in their financial, physical, and mental wellbeing. Our Benefits: An annual performance bonus for all team members Generous 401(k) company match that is immediately vested A choice of three medical plans (that include prescription drug coverage) to suit your unique needs. For High Deductible Health Plan enrollees, a company contribution to your Health Savings Account Multiple options for dental and vision coverage Company provided Life & Disability Insurance to ensure financial protection when you need it most Family friendly benefits including Paid Parental Leave & Adoption Assistance Hybrid work arrangements for eligible roles Tuition Reimbursement and Continuing Professional Education Paid Time Off - new hires start with at least 20 days of PTO per year in addition to nine company paid holidays. As you grow with us, your PTO may increase based on your level within the company and years of service. Volunteer days, community partnerships, and Employee Assistance Program Ability to connect with colleagues around the country through our Employee Resource Group program Our Values: Integrity Empowerment Compassion Collaboration Fun EEO Statement Reliance Matrix is an equal opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, national origin, citizenship, age or disability, or any other classification or characteristic protected by federal or state law or regulation. We assure you that your opportunity for employment depends solely on your qualifications. #LI-Remote #LI-MR1

Responsibilities & Duties:Claims Processing and Assessment: Evaluate incoming claims to determine eligibility, coverage, and validity. Conduct thorough investigations, including reviewing medical records and other relevant documentation. Analyze policy provisions and contractual agreements to assess claim validity. Utilize claims management systems to document findings and process claims efficiently. Communication and Customer Service: Communicate effectively with policyholders, beneficiaries, and healthcare providers regarding claim status and requirements. Provide timely responses to inquiries and maintain professional and empathetic communication throughout the claims process. Address customer concerns and escalate complex issues to senior claims personnel or management as needed. Compliance and Documentation: Ensure compliance with company policies, procedures, and regulatory requirements. Maintain accurate records and documentation related to claims activities. Follow established guidelines for claims adjudication and payment authorization. Quality Assurance and Improvement: Identify opportunities for process improvement and efficiency within the claims department. Participate in quality assurance initiatives to uphold service standards and improve claim handling practices. Collaborate with team members and management to implement best practices and enhance overall departmental performance. Reporting and Analysis: Generate reports and provide data analysis on claims trends, processing times, and outcomes. Contribute to the development of management reports and presentations regarding claims operations.

At OneAmerica, we deliver on promises when customers need us most. We believe the best way to serve our customers is to know that every individual, employee, family and business we work with has unique personal and financial goals. We keep our promises, so we can help them achieve their goals and realize their definition of financial success. Job Summary The STD Claims Examiner is responsible for contributing to the overall success of OneAmerica objectives by providing timely and accurate support to our client companies and the Claims department. This individual will be responsible for managing appropriate adjudication of short-term disability claims in accordance with policy provisions. The STD Claims Examiner will initiate and facilitate case management as well as other ancillary services to assure optimum outcomes. We are currently seeking Level I & II Representative experience. KEY RESPONSIBILITIES: Promote a positive customer service image through prompt, accurate and courteous responses to customer information needs Consistently adhere to the documented workflow guidelines and established procedures. Maintain required levels of confidentiality Demonstrate competency in all modules of training program. Remain abreast of industry standards via internal/external continuing education Promptly and thoroughly investigate and evaluate claims within departmental and regulatory guidelines Interpret and administer contract provisions including, but not limited to, eligibility, covered weekly earnings, definition of Total Disability, verification of applicable offsets and pre-existing investigations Calculate benefit and identify other income replacement benefits. Processes financial activities, including, but not limited to, payment adjustments, stop payments, voids and check reissues, other income adjustments, reimbursement checks, and final benefits. Processes overpayments in accordance with established procedures Assist in the subrogation process to recover money from third parties Work in coordination with an LTD Examiner to ensure an appropriate transition from the STD claim to LTD Document claim file actions and telephone conversations appropriately Refer claim activity outside authority level to Supervisor/Manager for review Proactively communicate with claimants, policyholders and physicians to resolve investigations issues Establish, communicate and manage claimant and policyholder expectations Utilize most efficient means to obtain claim information Fully investigates all relevant claim issues, provides payment or denials promptly and in full compliance with departmental procedures and Unfair Claims Practice regulations Respond to customer service issues within required timeframes Involve technical resources (Social Security Specialist, medical resources and vocational resources) at appropriate claim junctures Support relationships with technical resources to achieve appropriate outcomes Meet or exceed departmental service, quality and production objectives Collaborate with team members and management in identifying and implementing improvement opportunities. Informs Supervisor of any trends noted within specific client companies All other duties as assigned REQUIREMENTS: BA/BS or equivalent combination of education and experience 0-2+ years of experience in managing Short Term Disability claims with first pay authority Ability to fluently speak and write Spanish a plus Excellent customer service skills Excellent math and calculation skills Good decision-making skills Ability to analyze complex claim information Working knowledge of Microsoft Excel and Word High School Diploma required, or any combination of education and experience which would provide an equivalent background. Salary Band: 3C #LI-SC1 This selected candidate will be expected to work hybrid in Portland, ME. The candidate will also be expected to physically return to the office in CA, IN or ME as business needs dictate or for team-building and collaboration. If you are offered and accept this position, please be advised that OneAmerica Financial does not have any offices located in the State of New York and OneAmerica Financial associates are not permitted to work remotely in the State of New York. Disclaimer: OneAmerica Financial is an equal opportunity employer and strictly prohibits unlawful discrimination based upon an individual's race, color, religion, gender, sexual orientation, gender identity/expression, national origin/ancestry, age, mental/physical disability, medical condition, marital status, veteran status, or any other characteristic protected by law. For all positions: Because this position is regulated by the Violent Crime Control and Law Enforcement Act, if an offer is made, applicants must undergo mandated background checks as a condition of employment. Such background checks include criminal history. A conviction is not necessarily an absolute bar to employment. Consistent with applicable regulatory guidelines and law, factors such as the age of the offense, evidence of rehabilitation, seriousness of violation, and job relatedness are considered. To learn more about our products, services, and the companies of OneAmerica Financial, visit oneamerica.com/companies.

Job Description At OneAmerica, we deliver on promises when customers need us most. We believe the best way to serve our customers is to know that every individual, employee, family and business we work with has unique personal and financial goals. We keep our promises, so we can help them achieve their goals and realize their definition of financial success. Job Summary The STD Claims Examiner is responsible for contributing to the overall success of OneAmerica objectives by providing timely and accurate support to our client companies and the Claims department. This individual will be responsible for managing appropriate adjudication of short-term disability claims in accordance with policy provisions. The STD Claims Examiner will initiate and facilitate case management as well as other ancillary services to assure optimum outcomes. We are currently seeking Level I & II Representative experience. KEY RESPONSIBILITIES: Promote a positive customer service image through prompt, accurate and courteous responses to customer information needs Consistently adhere to the documented workflow guidelines and established procedures. Maintain required levels of confidentiality Demonstrate competency in all modules of training program. Remain abreast of industry standards via internal/external continuing education Promptly and thoroughly investigate and evaluate claims within departmental and regulatory guidelines Interpret and administer contract provisions including, but not limited to, eligibility, covered weekly earnings, definition of Total Disability, verification of applicable offsets and pre-existing investigations Calculate benefit and identify other income replacement benefits. Processes financial activities, including, but not limited to, payment adjustments, stop payments, voids and check reissues, other income adjustments, reimbursement checks, and final benefits. Processes overpayments in accordance with established procedures Assist in the subrogation process to recover money from third parties Work in coordination with an LTD Examiner to ensure an appropriate transition from the STD claim to LTD Document claim file actions and telephone conversations appropriately Refer claim activity outside authority level to Supervisor/Manager for review Proactively communicate with claimants, policyholders and physicians to resolve investigations issues Establish, communicate and manage claimant and policyholder expectations Utilize most efficient means to obtain claim information Fully investigates all relevant claim issues, provides payment or denials promptly and in full compliance with departmental procedures and Unfair Claims Practice regulations Respond to customer service issues within required timeframes Involve technical resources (Social Security Specialist, medical resources and vocational resources) at appropriate claim junctures Support relationships with technical resources to achieve appropriate outcomes Meet or exceed departmental service, quality and production objectives Collaborate with team members and management in identifying and implementing improvement opportunities. Informs Supervisor of any trends noted within specific client companies All other duties as assigned REQUIREMENTS: BA/BS or equivalent combination of education and experience 0-2+ years of experience in managing Short Term Disability claims with first pay authority Ability to fluently speak and write Spanish a plus Excellent customer service skills Excellent math and calculation skills Good decision-making skills Ability to analyze complex claim information Working knowledge of Microsoft Excel and Word High School Diploma required, or any combination of education and experience which would provide an equivalent background. Salary Band: 3C #LI-SC1 This selected candidate will be expected to work hybrid in Portland, ME. The candidate will also be expected to physically return to the office in CA, IN or ME as business needs dictate or for team-building and collaboration. If you are offered and accept this position, please be advised that OneAmerica Financial does not have any offices located in the State of New York and OneAmerica Financial associates are not permitted to work remotely in the State of New York. Disclaimer: OneAmerica Financial is an equal opportunity employer and strictly prohibits unlawful discrimination based upon an individual's race, color, religion, gender, sexual orientation, gender identity/expression, national origin/ancestry, age, mental/physical disability, medical condition, marital status, veteran status, or any other characteristic protected by law. For all positions: Because this position is regulated by the Violent Crime Control and Law Enforcement Act, if an offer is made, applicants must undergo mandated background checks as a condition of employment. Such background checks include criminal history. A conviction is not necessarily an absolute bar to employment. Consistent with applicable regulatory guidelines and law, factors such as the age of the offense, evidence of rehabilitation, seriousness of violation, and job relatedness are considered. To learn more about our products, services, and the companies of OneAmerica Financial, visit oneamerica.com/companies.

Sun Life U.S. is one of the largest providers of employee and government benefits, helping approximately 50 million Americans access the care and coverage they need. Through employers, industry partners and government programs, Sun Life U.S. offers a portfolio of benefits and services, including dental, vision, disability, absence management, life, supplemental health, medical stop-loss insurance, and healthcare navigation. We have more than 6,400 employees and associates in our partner dental practices and operate nationwide. Visit our website to discover how Sun Life is making life brighter for our customers, partners and communities. Job Description: The Opportunity: This position is responsible for reviewing claims, interpreting and comparing contracts, dispersing reimbursement, and ensuring that all claims contain the required documentation to support the Stop Loss claim determination. They are responsible for customer service, and the financial risk associated with an assigned block of Stop Loss claims. This requires applying the appropriate contractual provisions; plan specifications of the underlying plan document; professional case management resources; and claims practices, procedures and protocols to the medical facts of each claim to decide on reimbursement or denial of a claim. The incumbent is accountable for developing, coordinating and implementing a plan of action for each claim accepted to ensure it is managed effectively and all cost containment initiatives are implemented in conjunction with the clinical resources. How you will contribute: * Determine, on a timely basis, the eligibility of assigned claim by applying the appropriate contractual provisions to the medical facts and specifications of the claim * The ability to apply the appropriate contractual provisions (both from the underlying plan of the policyholder as well as the Sun Life contract) especially with regard to eligibility and exclusions * Maintain claim block and meet departmental production and quality metrics * An awareness of industry claim practices * Prepare written rationale of claim decision based on review of the contractual provisions and plan specifications and the analysis of medical records * Knowledge of legal risk and regulatory/statutory guidelines HIPPA, privacy, Affordable Health Care Act, etc. * Understand where, when and how professional resources both internal and external, e.g. medical, investigative and legal can add value to the process * Establish cooperative and productive relationships with professional resources What you will bring with you: * Bachelor's degree preferred * A minimum of three to five years' experience processing first dollar medical claims or stop loss claim processing * Demonstrated ability to work as part of a cohesive team * Strong written and verbal communication skills * Knowledge of Stop Loss Claims and Stop Loss industry preferred * Demonstrated success in negotiation, persuasion, and solutions-based underwriting * Ability to work in a fast-paced environment; flexibility to handle multiple priorities while maintaining a high level of professionalism * Overall knowledge of health care industry * Proficiency using the Microsoft Office suite of products * Ability to travel Salary Range: $54,900 - $82,400 At our company, we are committed to pay transparency and equity. The salary range for this role is competitive nationwide, and we strive to ensure that compensation is fair and equitable. Your actual base salary will be determined based on your unique skills, qualifications, experience, education, and geographic location. In addition to your base salary, this position is eligible for a discretionary annual incentive award based on your individual performance as well as the overall performance of the business. We are dedicated to creating a work environment where everyone is rewarded for their contributions. Not ready to apply yet but want to stay in touch? Join our talent community to stay connected until the time is right for you! We are committed to fostering an inclusive environment where all employees feel they belong, are supported and empowered to thrive. We are dedicated to building teams with varied experiences, backgrounds, perspectives and ideas that benefit our colleagues, clients, and the communities where we operate. We encourage applications from qualified individuals from all backgrounds. Life is brighter when you work at Sun Life At Sun Life, we prioritize your well-being with comprehensive benefits, including generous vacation and sick time, market-leading paid family, parental and adoption leave, medical coverage, company paid life and AD&D insurance, disability programs and a partially paid sabbatical program. Plan for your future with our 401(k) employer match, stock purchase options and an employer-funded retirement account. Enjoy a flexible, inclusive and collaborative work environment that supports career growth. We're proud to be recognized in our communities as a top employer. Proudly Great Place to Work Certified in Canada and the U.S., we've also been recognized as a "Top 10" employer by the Boston Globe's "Top Places to Work" for two years in a row. Visit our website to learn more about our benefits and recognition within our communities. We will make reasonable accommodations to the known physical or mental limitations of otherwise-qualified individuals with disabilities or special disabled veterans, unless the accommodation would impose an undue hardship on the operation of our business. Please email ************************* to request an accommodation. For applicants residing in California, please read our employee California Privacy Policy and Notice. We do not require or administer lie detector tests as a condition of employment or continued employment. Sun Life will consider for employment all qualified applicants, including those with criminal histories, in a manner consistent with the requirements of applicable state and local laws, including applicable fair chance ordinances. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. Job Category: Claims - Life & Disability Posting End Date: 30/01/2026

The Claim Specialist III investigates, evaluates, negotiates, and resolves lost time claims within settlement and reserving authority up to stated maximum. (Supervisor will determine actual individual authority up to the stated maximum). Conducts training classes (including research and position papers) for less experienced Claim Department Representatives. Based on experience and proven ability, an expanded and more difficult caseload will be expected, requiring a lesser degree of supervision. Principal Duties and Responsibilities: Communicates with insureds, injured workers, agents, brokers, witnesses, attorneys, loss prevention, and underwriters to obtain and relate necessary information to determine coverage/compensability, facts of loss, and degree of liability/exposure. Maintains contact throughout the life of the file as needed. Administers the delivery of timely, appropriate and accurate indemnity and medical benefits. Evaluates claim exposure, negotiate and resolve claims. Works closely with defense counsel on litigated cases and attend mediation, arbitration, and hearings, as necessary. Develops litigation plan with defense counsel and tracks adherence to plan in order to control legal expenses and assure effective resolution. Works closely with insureds and employees making visitations and presentations as needed to facilitate partnership approach to claims handling. Maintains quality claim files in accordance with appropriate best practices, and other company procedures. Implements Managed Care strategies, coordinate rehabilitation or medical management, process bills, review all mail through Image Right, and monitor progress as appropriate. Interacts with State and Federal Boards and Commissions, while establishing and maintaining proper reserves, as appropriate. Serves as a mentor and helps prepare/train the less experienced Claim Department representatives. Keeps up-to-date on State laws and Company procedures relating to various claims; educates injured worker and/or insured on same. Prepares and presents files for Agent/Broker Reviews and Insured File Review. Understands medical terminology and standard medical procedures as they pertain to worker's compensation, U.S. Longshoreman's and Jones Act claims. Participates in in-house and outside training programs to keep up-to-date on relevant issues/topics. Maintains a working knowledge of all computer systems currently in use. Continues education in claims through Associate in Claims or Claims Law (AEI) courses. Requirements: Three years of workers' compensation lost time claim handling experience required. Bachelor's degree preferred. Computer skills, Word, Excel and Image Right preferred. Must have valid driver's license. Strong attention to detail and strong communication skills both verbal and written. Adaptable/flexible and self-directed with the ability to manage time and other resources wisely. Must have the ability to work effectively with other organizational team members. Our comprehensive benefits package includes all traditional offerings such as: Health Insurance options, Dental Insurance options and Vision Insurance Employee Life Insurance/AD&D and Dependent Life Insurance options Short-term & Long-term Disability Health Savings Account with potential employer match Flexible Medical and Dependent Care Account Accident Insurance Critical Illness Insurance Employee Assistance Program Legal/Identify Theft Insurance options Long Term Care Insurance Pet Insurance 401 (k) Retirement Plan with match up to 5%, plus profit sharing & discretionary contributions (subject to vesting) 5 weeks of Paid Time Off (PTO) 11 paid holidays We also offer other benefits to help foster a healthy, balance lifestyle such as: Flextime schedules Paid Parental Leave Student loan paydown and refinancing assistance Educational assistance for job related courses, seminars, certifications or degrees One paid day every year to volunteer for your non-profit of choice On-site fitness center (Maine only) or fitness reimbursement Subsidized parking Sit-Stand desks & daily stretch breaks MEMIC is committed to a policy of nondiscrimination and equal opportunity for all employees and qualified applicants without regard to race, color, religious creed, national origin, ancestry, age, disability, genetics, gender identity, veteran's status, sexual orientation, or any other characteristic protected by law. #IND2022

When you join the team at Unum, you become part of an organization committed to helping you thrive. Here, we work to provide the employee benefits and service solutions that enable employees at our client companies to thrive throughout life's moments. And this starts with ensuring that every one of our team members enjoys opportunities to succeed both professionally and personally. To enable this, we provide: + Award-winning culture + Inclusion and diversity as a priority + Performance Based Incentive Plans + Competitive benefits package that includes: Health, Vision, Dental, Short & Long-Term Disability + Generous PTO (including paid time to volunteer!) + Up to 9.5% 401(k) employer contribution + Mental health support + Career advancement opportunities + Student loan repayment options + Tuition reimbursement + Flexible work environments **_*All the benefits listed above are subject to the terms of their individual Plans_** **.** And that's just the beginning... With 10,000 employees helping more than 39 million people worldwide, every role at Unum is meaningful and impacts the lives of our customers. Whether you're directly supporting a growing family, or developing online tools to help navigate a difficult loss, customers are counting on the combined talents of our entire team. Help us help others, and join Team Unum today! **General Summary:** Minimum starting hourly rate is $22.60 This is an entry level position within the Voluntary Benefits Claims Organization. This position is responsible for the thorough, fair, objective, and timely adjudication of voluntary benefits claims in conjunction with providing technical expertise regarding applicable regulations. This position is responsible for providing excellent customer service and interacts on a regular basis with employees, employers, health care providers and other specialized internal resources. Incumbents in this role are considered trainees and are assigned a formal mentor for 6-12 months until they are assessed as capable of independent work. Incumbents are primarily responsible for learning and developing the skills, knowledge, and behaviors necessary to successfully adjudicate assigned claims, in accordance with our claims philosophy and policies and procedures. Incumbent must demonstrate the ability to effectively manage an assigned caseload, exercise discretion and independent judgment, and appropriately render timely claim decisions while demonstrating strong customer service prior to movement to the exempt level claims specialist role. **Principal Duties and Responsibilities:** + Maintain organizational service standards on all assigned claims demonstrating success in developing and implementing effective strategies to manage a caseload of varying size and complexity. + Develop an understanding and working knowledge of Voluntary Benefits for Unum and Colonial Life, including products, policies, procedures, and contracts. + Develop an understanding of the applicable contract/policy definitions and relevant provisions, clauses, exclusions, riders, and waivers, as well as regulatory and statutory requirements for claim products administered. + Develop skill set to determine appropriate risk management strategies through analyzing and applying technical and complex contractual knowledge (policies and provisions) to ensure appropriate eligibility requirements, liability decisions, and benefits payee. + Develop problem solving skills by demonstrating analytical and logical thinking resulting in the timely and accurate adjudication of a variety of simple to complex voluntary benefits claims. + Develop a working knowledge of systems needed for claims adjudication. + Provide excellent customer service and independently respond to all inquiries within service guidelines. + Responsible for timely and accurate claims review, initiation and completion of appropriate claim validation activities, and referrals/notifications to other areas (i.e., medical assessments, billing, etc.) as appropriate. + Produce objective, clear documentation and technical rationale for all claim determinations and demonstrate the ability to effectively communicate determinations while ensuring compliance with Voluntary Benefits procedures and all legal requirements including state regulations. + Partner and coordinate file strategies utilizing specialized resources including nurses, physicians, vocational rehabilitation and assessing medical documentation, when appropriate. + Ensure a timely and well communicated transfer process when transitioning integrated claims across lines of business, ensuring a coordinated and continuous claims experience for customers. + Be familiar with specialized workflow requirements and performance standards for any assigned customers. + May perform other duties as assigned. **Job Specifications:** + 4-year degree preferred or equivalent work experience + Ability to develop Voluntary Benefits product knowledge and apply a best-in-class service experience + Medical background, voluntary benefits claims and/or disability management experience preferred + Possess strong analytical, critical thinking, and problem-solving skills + Ability to exercise independent judgment and discretion in increasingly complex claim adjudication decisions, including initial decision and ongoing medical management. + Able to effectively utilize a broad spectrum of resources, materials, and tools needed to assist with the decision-making process + Strong service and quality orientation. + Ability to interact effectively and professionally with claimants, employers, medical resources, attorneys, accountants, brokers, sales representatives, etc. + Demonstrated ability to operate with a sense of urgency and make balanced decisions with the highest degree of integrity and fairness. + Excellent communication skills, written and verbal + Meets the standards for this position, as defined in the Talent Management framework ~IN3 \#LI-LM2022 Unum and Colonial Life are part of Unum Group, a Fortune 500 company and leading provider of employee benefits to companies worldwide. Headquartered in Chattanooga, TN, with international offices in Ireland, Poland and the UK, Unum also has significant operations in Portland, ME, and Baton Rouge, LA - plus over 35 US field offices. Colonial Life is headquartered in Columbia, SC, with over 40 field offices nationwide. Unum is an equal opportunity employer, considering all qualified applicants and employees for hiring, placement, and advancement, without regard to a person's race, color, religion, national origin, age, genetic information, military status, gender, sexual orientation, gender identity or expression, disability, or protected veteran status. The base salary range for applicants for this position is listed below. Unless actual salary is indicated above in the job description, actual pay will be based on skill, geographical location and experience. $40,000.00-$75,600.00 Additionally, Unum offers a portfolio of benefits and rewards that are competitive and comprehensive including healthcare benefits (health, vision, dental), insurance benefits (short & long-term disability), performance-based incentive plans, paid time off, and a 401(k) retirement plan with an employer match up to 5% and an additional 4.5% contribution whether you contribute to the plan or not. All benefits are subject to the terms and conditions of individual Plans. Company: Unum

At WelbeHealth, we are transforming the reality of senior care by providing an all-inclusive healthcare option (PACE) to the most vulnerable senior population while serving as a care provider and care plan to those individuals we serve. Our Health Plan Services team helps ensure excellent care delivery for our participants, and the Claims Audit Analyst plays a pivotal role in ensuring timely and accurate pre-payment or denial of claims while meeting federal/state regulations, provider agreements terms, and/or company policies and procedures. **Essential Job Duties:** + Review processed claims for accuracy prior to payment while maintaining acceptable levels of claim's aged inventory by verifying various aspects of the system and claim + Complete and maintain detailed documentation of audit findings which include decision methodology, system or processing errors, and monetary discrepancies + Move claims free of processing errors through for full adjudication and return claims with errors back to the claims team for corrections + Provide feedback to the Oversight & Monitoring Manager on claims processing errors, quality improvement opportunities, and configuration change requests, when applicable **Job Requirements:** + Minimum of three (3) years of experience processing and auditing Medicare and Medicaid professional, institutional, and dental health insurance claims + Experience working with CMS and Medicaid healthcare claims highly preferred + Demonstrated skills within Microsoft Office Applications, including Excel **Benefits of Working at WelbeHealth:** Apply your claims expertise in meaningful ways as we rapidly expand. You will have the opportunity to design the way we work in the context of an encouraging and loving environment where every person feels uniquely cared for. + Medical insurance coverage (Medical, Dental, Vision) starting day one of employment + Work/life balance - we mean it! 17 days of personal time off (PTO), 12 holidays observed annually, sick time + Advancement opportunities - We've got a track record of hiring and promoting from within, meaning you can create your own path! + And additional benefits Salary/Wage base range for this role is $68,640 - $77,519 / year + Bonus. WelbeHealth offers competitive total rewards package that includes, 401k match, healthcare coverage and a broad range of other benefits. Actual pay will be adjusted based on experience and other qualifications. Compensation $68,640-$77,519 USD **COVID-19 Vaccination Policy** At WelbeHealth, our mission is to unlock the full potential of our vulnerable seniors. In this spirit, please note that we have a vaccination policy for all our employees and proof of vaccination, or a vaccine declination form will be required prior to employment. WelbeHealth maintains required infection control and PPE standards and has requirements relevant to all team members regarding vaccinations. **Our Commitment to Diversity, Equity and Inclusion** At WelbeHealth, we embrace and cherish the diversity of our team members, and we're committed to building a culture of inclusion and belonging. We're proud to be an equal opportunity employer. People seeking employment at WelbeHealth are considered without regard to race, color, religion, sex, gender, gender identity, gender expression, sexual orientation, marital or veteran status, age, national origin, ancestry, citizenship, physical or mental disability, medical condition, genetic information or characteristics (or those of a family member), pregnancy or other status protected by applicable law. **Beware of Scams** Please ensure your application is being submitted through a WelbeHealth sponsored site only. Our emails will come from @welbehealth.com email addresses. You will never be asked to purchase your own employment equipment. You can report suspected scam activity to ****************************

Part-time Description Do you have experience with medical billing and coding? Do you have a keen eye for detail and a passion for accuracy? Consider joining our small office team as a Provider Practice Billing & Claims Specialist and play a vital role in ensuring smooth, efficient billing processes that directly impact patient care. This is your chance to combine your expertise with a mission-driven environment where your work will make a positive impact on the lives of over 600 Maine seniors. Hiring immediately! Composed of ten companies across the great state of Maine, Woodlands Senior Living provides a residence for more than 700 seniors to age gracefully, happily, and comfortably surrounded by compassionate caregivers. All ten of those companies have become the first in Maine to receive Joint Commission accreditation! On a mission to make each day the best day possible for every resident served, we have embarked on yet another ground-breaking concept - a senior living provider practice. What you will do as a Provider Practice Billing & Claims Specialist: Utilizes clinical and coding knowledge to ensure accurate and compliant diagnostic and procedural assignments are captured to optimize reimbursement for professional charges, utilizing ICD-10-CM, CPT-4 and sequencing best-practices. Submits accurate and timely claims to payors. Receives payments from payors and performs data entry of payments and account adjustments. Informs Accounting Supervisor of accounting discrepancies. Performs error analysis for denied claims and provides recommendations for process improvements and claim reimbursement resolution. Escalates concerns to Accounting Supervisor. Acts as liaison and subject matter expert to internal and external stakeholders, delivering expert guidance and training related to coding systems, required documentation, payer requirements, and industry standards. This is a 20 - 24 hour position. The benefits to join the team: Vacation and holiday pay because you deserve time to relax and recharge Tuition assistance because we believe in the investment of your growth and success Health, dental, vision and supplemental benefits to support your health 401(k) savings and investment plan to prepare for your future Requirements What you'll bring to the role: Two or more years of previous experience as a medical biller/coder preferred Proficient with Microsoft Office products preferred. Must provide proof of immunization/immunity to MMR, Varicella and Influenza A current, valid license to operate a vehicle in the state of Maine and a driving record that is satisfactory to the company may be required Strong command of the English language with the ability to follow oral and written instructions with precision Salary Description $21 - $29 / hour

Associate Claims Representatives handle entry-level insurance claims under close supervision through the life-cycle of a claim including but not limited to: investigation, evaluation and claim resolution. The purpose of this position is to provide service to agents, insureds and others to ensure claims resolve accurately and timely. Associate Claims Representatives are enrolled in a structured training program that is designed to promote professional development and advancement within our company through extensive hands-on training, as well as educational resources to gain a strong foundation of industry knowledge. Successful Claims Adjusters will excel in this role and be prepared for future roles within Concord Group Insurance. Responsibilities Investigate, evaluate, and settle entry-level insurance claims Study insurance policies, endorsements, and forms to develop foundational product knowledge Learn and comply with Company claim handling procedures Develop claim negotiation and settlement skills Meet and communicate with claimants, legal counsel, and third parties Develop specialized skills including but, not limited to estimating and use of designated computer-based programs for loss adjustment Requirements Associate's degree required; bachelor's degree preferred, or equivalent industry exposure/experience Ability to succeed with key training milestones Apply basic problem resolution skills and effective interpersonal skills Read, interpret, and respond to documents such as insurance policies, procedure manuals, and legal documents at a foundational level Accurately solve mathematical problems, including basic geometry (area and volume) and financial statements (such as accuracy in sums and unit costs) Benefits At The Concord Group, we're proud to offer a comprehensive benefits package designed to support the wellbeing of our associates. This includes medical, vision, dental, life insurance, disability insurance, and a generous paid time off program for vacation, personal, sick time, and holiday pay. Additional benefits include parental leave, adoption assistance, fertility treatment assistance, a competitive 401(k) plan with company match, gym member/fitness class reimbursement, and additional resources and programs that encourage professional growth and overall wellness. Why Concord Group Insurance Since 1928, The Concord Group has been protecting families and small businesses across New England with trusted, personal insurance solutions. The Concord Group is a member of The Auto Owners Group of Companies and is recognized as a leading insurance provider through the independent agency system. Rated A+ (Superior) by AM Best, the company is represented by more than 550 of the best local independent agents throughout Maine, Massachusetts, New Hampshire, and Vermont. At Concord Group, we believe in more than just insurance, we believe in our people. Our associates thrive in a supportive, collaborative workplace where community involvement, professional growth, and shared values drives everything we do. Starting your career with The Concord Group means joining a team that values people first and gives you the opportunity to grow, give back, and make a lasting difference in the lives of those we serve. Compensation We are dedicated to fair and competitive total compensation package that supports the wellbeing and success of our associates. In addition to this, we offer other components like bonus opportunities. For this position, the anticipated annualized starting base pay range is: $50,000 - $65,000. Equal Employment Opportunity The Concord Group is an equal opportunity employer and hires, transfers, and promotes based on 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. The Concord Group participates in E-Verify.

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 SummaryReviews 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 Hours40Time TypeFull time Pay RangeThe typical pay range for this role is:$18. 50 - $42. 35This 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 ************* cvshealth. com/us/en/benefits We anticipate the application window for this opening will close on: 02/27/2026Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Your Next Opportunity Is Here - Urgently Hiring Provider Services Representatives in Portland, ME! Job Title: Provider Services Representative Pay: $19.22 - $24.88 per hour Hours: Full-time, 40 hours per week (Monday-Friday, 8:00/8:30 AM - 4:30/5:00 PM) Start Date: ASAP Looking for a professional role in health care administration where you can make a difference through service and support? Join a mission-driven, not-for-profit health care organization as a Provider Services Representative in Portland, ME, and help ensure providers have the information and assistance they need to deliver excellent care to their patients. As a Provider Services Representative, you'll respond to provider inquiries related to coverage, claims, and billing while ensuring accuracy, timeliness, and professionalism in every interaction. You'll work closely with diverse teams within the organization to deliver solutions that reflect our core values of trust, respect, and service. What You'll Do As a Provider Services Representative, you will be responsible for: Answering verbal, written, and electronic inquiries from providers regarding coverage, claims, billing, and payments. Providing accurate information and educating providers about program policies and procedures. Handling incoming calls and ensuring timely resolution of all inquiries. Coordinating with internal departments to address and resolve provider issues effectively. Staying current with updates, policies, and procedures through internal systems. Documenting provider interactions thoroughly and accurately. Delivering professional, courteous, and friendly service to both internal and external customers. What You'll Bring The ideal candidate for this role will have: A high school diploma or equivalent. At least 3 years of customer service experience (health care or call center preferred). Medical billing experience (preferred). Strong computer skills and data entry proficiency with high accuracy. Ability to talk and type simultaneously. Excellent communication, listening, and problem-solving skills. Strong organizational skills and the ability to multitask effectively. A professional, calm, and adaptable demeanor under pressure. Demonstrated commitment to values of trust, respect, teamwork, and service. U.S. citizenship (may be required for government trustworthiness clearance). Why Join Us in Portland? Meaningful work supporting providers and improving community health outcomes. Flexible work environment with remote capability and occasional on-site collaboration. Affordable health and prescription coverage with no waiting period. Comprehensive benefits offered once hired permanently. Referral Bonus Program - earn extra cash for successful referrals. Location & Schedule This position is based in Portland, ME, with remote flexibility and occasional on-site work required. Work hours are Monday-Friday, 8:00/8:30 AM - 4:30/5:00 PM. Ready to Take the Next Step? If you're ready to start a rewarding career as a Provider Services Representative in Portland, ME, apply today or contact our recruiting team to learn more. Don't wait - we're hiring now!

If you are a current State of Maine employee, you must complete your application through the internal application process (Find Jobs Report). Please apply using your PRISM account. If you are on Seasonal Leave and do not have access to PRISM, contact your local Human Resources representative for application information. Department of Labor Job Class Code: 0686 Grade: 21/Professional & Technical Salary: $21.54-$30.14/Hour Location: Presque Isle Opening Date: January 7, 2026 Closing Date: January 22, 2026 The Maine Department of Labor is seeking a detail-oriented and impartial Unemployment Claims Adjudicator to join our team. This position plays a critical role in evaluating unemployment benefit claims, interpreting state and federal laws, and ensuring program integrity. You will conduct investigations, make legally sound determinations, and support the fair administration of unemployment benefits. Why Work With Us Purposeful Work: Help ensure fairness and integrity in public benefit programs. Professional Growth: Learn, grow, and contribute in a dynamic regulatory environment. Supportive Team: Collaborate with a dedicated, mission-driven team. Primary responsibilities include: Interview claimants, employers, and witnesses-primarily by phone-to determine benefit eligibility and chargeable employer accounts. Analyze employment history, wage data, and separation information to reach accurate determinations. Write clear, well-reasoned decisions based on evidence and applicable laws. Explain laws, regulations, and policies to claimants, employers, and the public. Represent the Department in appeal hearings and court proceedings, providing testimony to support decisions. Investigates, research, and documents allegations of misrepresentation and fraudulent claims in order to determine validity and prepare reports of investigation. Plan, assign, and review work of support staff; provide training and oversight to ensure consistent and equitable application of rules. Knowledge of: Interviewing and investigative techniques. Research techniques and practices. Labor-management relations. Federal and state laws, rules, regulations, precedent cases, and agency manuals governing UC programs. Policies and procedures relating to the prevention, detection, and recovery of overpayments. Public sector and private industry employment practices. Quality Control Program goals and objectives. Ability to: Communicate effectively. Write clearly and effectively. Determine benefit eligibility. Interpret and apply laws, rules, and regulations in specific circumstances. Compile and analyze facts, reach logical conclusions, and make sound recommendations. Deal effectively with irate or confused clients. Demonstrate competent time management. Use desktop and laptop computers. Write complete and understandable decisions and reports. Plan, direct, and coordinate the work of subordinate staff. Train subordinate personnel Minimum qualifications: A Bachelors Degree in Business Administration, Human Resources, Economics, Finance, or related field and two (2) years of technical, administrative, or paraprofessional support level experience in public contact work which demonstrates interviewing, data gathering, and analytical skills. Comparable work experience may be substituted for education on a year-for-year basis. Preference will be given to those applicants: Experience adjudicating unemployment or public benefits claims Knowledge of Maine Employment Security Law Contact information: Questions about this position should be directed to ************************ Benefits of working for the State of Maine: No matter where you work across Maine state government, you find employees who embody our state motto-"Dirigo" or "I lead"-as they provide essential services to Mainers every day. We believe in supporting our workforce's health and wellbeing with a valuable total compensation package, including: Work-Life Fit - Rest is essential. Take time for yourself using 13 paid holidays, 12 days of sick leave, and 3+ weeks of vacation leave annually. Vacation leave accrual increases with years of service, and overtime-exempt employees receive personal leave. Health Insurance Coverage - The State of Maine pays 85%-95% of employee-only premiums ($11,196.96 - $12,514.32 annual value), depending on salary. Use this chart to find the premium costs for you and your family, including the percentage of dependent coverage paid by the State. Dental Insurance - The State of Maine pays 100% of employee-only dental premiums ($387.92 annual value). Retirement Plan - The State contributes the equivalent of 14.11% of the employee's pay towards the Maine Public Employees Retirement System (MainePERS) for MSEA, or 18.91% for Confidential employees. State employees are eligible for an extensive and highly competitive benefits package, covering many aspects of wellness. Learn about additional wellness benefits for State employees from the Office of Employee Health and Wellness. Note: Benefits may vary somewhat according to specific collective bargaining agreements and are prorated for anything less than full-time. There's a job and then there's purposeful, transformative work. Our aim is to create a workplace where you can learn, grow, and continuously refine your skills. Applicants demonstrate job requirements in differing ways, and we appreciate that many skills and backgrounds can make people successful in this role. As an Equal Opportunity employer, Maine State Government embraces a culture of respect and awareness. We are committed to creating a strong sense of belonging for all team members, and our process ensures an inclusive environment to applicants of all backgrounds including diverse race, color, sex, sexual orientation or gender identity, physical or mental disability, religion, age, ancestry, national origin, familial status or genetics. If you're looking for a great next step, and want to feel good about what you do, we'd love to hear from you. Please note reasonable accommodations are provided to qualified individuals with disabilities upon request. Thinking about applying? Research shows that people from historically excluded communities tend to apply to jobs only when they check every box in the posting. If you're currently reading this and hesitating to apply for that reason, we encourage you to go for it! Let us know how your lived experience and passion set you apart. . If you are unable to complete the online application, please contact the Human Resources representative listed on the job opening you are interested in applying for. They will work with you for an alternative method of submitting.

If you are a current State of Maine employee, you must complete your application through the internal application process (Find Jobs Report). Please apply using your PRISM account. If you are on Seasonal Leave and do not have access to PRISM, contact your local Human Resources representative for application information. Department of Labor Job Class Code: 0686 Grade: 21/Professional & Technical Salary: $21.54-$30.14/Hour Location: Presque Isle Opening Date: January 7, 2026 Closing Date: January 22, 2026 The Maine Department of Labor is seeking a detail-oriented and impartial Unemployment Claims Adjudicator to join our team. This position plays a critical role in evaluating unemployment benefit claims, interpreting state and federal laws, and ensuring program integrity. You will conduct investigations, make legally sound determinations, and support the fair administration of unemployment benefits. Why Work With Us * Purposeful Work: Help ensure fairness and integrity in public benefit programs. * Professional Growth: Learn, grow, and contribute in a dynamic regulatory environment. * Supportive Team: Collaborate with a dedicated, mission-driven team. Primary responsibilities include: * Interview claimants, employers, and witnesses-primarily by phone-to determine benefit eligibility and chargeable employer accounts. * Analyze employment history, wage data, and separation information to reach accurate determinations. * Write clear, well-reasoned decisions based on evidence and applicable laws. * Explain laws, regulations, and policies to claimants, employers, and the public. * Represent the Department in appeal hearings and court proceedings, providing testimony to support decisions. * Investigates, research, and documents allegations of misrepresentation and fraudulent claims in order to determine validity and prepare reports of investigation. * Plan, assign, and review work of support staff; provide training and oversight to ensure consistent and equitable application of rules. Knowledge of: * Interviewing and investigative techniques. * Research techniques and practices. * Labor-management relations. * Federal and state laws, rules, regulations, precedent cases, and agency manuals governing UC programs. * Policies and procedures relating to the prevention, detection, and recovery of overpayments. * Public sector and private industry employment practices. * Quality Control Program goals and objectives. Ability to: * Communicate effectively. * Write clearly and effectively. * Determine benefit eligibility. * Interpret and apply laws, rules, and regulations in specific circumstances. * Compile and analyze facts, reach logical conclusions, and make sound recommendations. * Deal effectively with irate or confused clients. * Demonstrate competent time management. * Use desktop and laptop computers. * Write complete and understandable decisions and reports. * Plan, direct, and coordinate the work of subordinate staff. * Train subordinate personnel Minimum qualifications: A Bachelors Degree in Business Administration, Human Resources, Economics, Finance, or related field and two (2) years of technical, administrative, or paraprofessional support level experience in public contact work which demonstrates interviewing, data gathering, and analytical skills. Comparable work experience may be substituted for education on a year-for-year basis. Preference will be given to those applicants: Experience adjudicating unemployment or public benefits claims Knowledge of Maine Employment Security Law Contact information: Questions about this position should be directed to ************************ Benefits of working for the State of Maine: No matter where you work across Maine state government, you find employees who embody our state motto-"Dirigo" or "I lead"-as they provide essential services to Mainers every day. We believe in supporting our workforce's health and wellbeing with a valuable total compensation package, including: * Work-Life Fit - Rest is essential. Take time for yourself using 13 paid holidays, 12 days of sick leave, and 3+ weeks of vacation leave annually. Vacation leave accrual increases with years of service, and overtime-exempt employees receive personal leave. * Health Insurance Coverage - The State of Maine pays 85%-95% of employee-only premiums ($11,196.96 - $12,514.32 annual value), depending on salary. Use this chart to find the premium costs for you and your family, including the percentage of dependent coverage paid by the State. * Dental Insurance - The State of Maine pays 100% of employee-only dental premiums ($387.92 annual value). * Retirement Plan - The State contributes the equivalent of 14.11% of the employee's pay towards the Maine Public Employees Retirement System (MainePERS) for MSEA, or 18.91% for Confidential employees. State employees are eligible for an extensive and highly competitive benefits package, covering many aspects of wellness. Learn about additional wellness benefits for State employees from the Office of Employee Health and Wellness. Note: Benefits may vary somewhat according to specific collective bargaining agreements and are prorated for anything less than full-time. There's a job and then there's purposeful, transformative work. Our aim is to create a workplace where you can learn, grow, and continuously refine your skills. Applicants demonstrate job requirements in differing ways, and we appreciate that many skills and backgrounds can make people successful in this role. As an Equal Opportunity employer, Maine State Government embraces a culture of respect and awareness. We are committed to creating a strong sense of belonging for all team members, and our process ensures an inclusive environment to applicants of all backgrounds including diverse race, color, sex, sexual orientation or gender identity, physical or mental disability, religion, age, ancestry, national origin, familial status or genetics. If you're looking for a great next step, and want to feel good about what you do, we'd love to hear from you. Please note reasonable accommodations are provided to qualified individuals with disabilities upon request. Thinking about applying? Research shows that people from historically excluded communities tend to apply to jobs only when they check every box in the posting. If you're currently reading this and hesitating to apply for that reason, we encourage you to go for it! Let us know how your lived experience and passion set you apart. . If you are unable to complete the online application, please contact the Human Resources representative listed on the job opening you are interested in applying for. They will work with you for an alternative method of submitting.

Provide Workers' Compensation (“WC”) claims adjusting in support of BIW's self-insured/self-administered WC program and provide guidance to injured employees. Effectively and efficiently manage a book of claims by reviewing open claims at a regular cadence and documenting medical management with internal and external providers. Timely review new claims for compensability determinations and processing qualified claimants in accordance with strict regulatory agency rules and regulations; and accurately file State and Federally mandated forms in accordance with strict agency rules and regulations. Operating under the BIW Business Operating System (BOS), the (Adjuster II/II) ensures compliance with safety, quality, and performance standards while coordinating with other key stakeholders to meet overall milestones. Key Responsibilities Safety Leadership: Identify and report out any and all opportunities for prevention or mitigation of injuries during the review of claims and related data & reports. Project Execution: Participate in the analysis of compliance reports and provide feedback as required. Assist in the process of internal and external financial and claim audits as required. Provide assistance and back-up for internal and external reporting, including quarterly CMS (Centers for Medicare & Medicaid Services) reconciliation reports. Evaluate claim exposure, establish case reserves, negotiate and resolve claims. Work closely with defense counsel on litigated claims to develop litigation plan. Attend mediation and hearings as necessary. Review for reasonableness and approval of medical invoices in accordance with treatment plans. Training and Development: Keep up to date on State and Federal laws as well as Medicare reporting requirements. Assist and educate employees and supervisors/managers on respective roles and responsibilities in managing WC claims. Team Collaboration and Communication: Work closely with Medical Dept., Operations, Human Resources, Labor Relations, and other functional areas to promote early return to work Other administrative duties as assigned by the Director of Risk Management. Continuous Improvement: Regular participation in process improvement and/or change management activities within the department and as part of larger teams. Identify opportunities for continuous process improvement and work closely with team members toward achieving same. Interact with State and Federal agencies to provide claim data and answer questions. Required/Preferred Education/Training Bachelor's Degree in Business Administration or equivalent combination of education and experience required. Required/Preferred Experience 2 years of experience with casualty claims management, or similar responsibilities required; experience in Workers' Compensation claims administration preferred. Advanced knowledge of MS Office required. Experience in process improvement and/or change management a plus. Experience with PeopleSoft, WFM, and ATS Claim System a plus. Knowledge of Federal and State regulatory compliance requirements a plus. Strong organizational, interpersonal, and communication skills. Self-motivated & team-oriented. High attention to detail required. Able to maintain confidentiality of highly sensitive information. Must have, or obtain, adjuster license within one year.

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015. Position Summary The Provider Service Representative I's major responsibility is to professionally respond to telephone inquiries from providers & related entities. The questions will be concerning but not limited to benefits, eligibility, plan coverage, enrollment status, claims adjudication process, billing, and payments for Martin's Point USFHP Program and Medicare programs. Job DescriptionKey Outcomes: Answers verbal, written and electronic inquiries with complete and accurate information and educates when possible regarding Martin's Point USFHP and Medicare program's policies, procedures and self- service options. Responds to incoming inquiries and partners with provider on possible next steps and or resolution. This should be completed within the timeframes outlined in Representative Expectations document. Collaborates with PI Research team and or other departments when needed to resolve Provider issues. Follows up in a timely manner with providers when first call resolution is not possible. Stays educated on existing and new information available through Provider Services internal resources. Documents all provider inquiries with accurate and detailed information according to correct template, including the resolution and next steps of the inquiry. Uses soft skills to build trusting relationships in the context of mutual partnership creating a world class service experience for internal and external customers. Education/Experience: High school diploma or equivalent. 3years of customer service experience. Requirements: Terms of employment may require the applicant/incumbent to qualify, obtain and maintain a Position Level of Trustworthiness from the U.S. Government Office of Personnel Management. Additionally, this position may require the applicant/incumbent to be a U.S. citizen. Skills/Knowledge/Competencies (Behaviors): Demonstrates an understanding of and alignment with Martin's Point Values. Excellent customer service skills Previous experience in a medical billing position preferred. Ability to work efficiently and independently. Analytical skills in research and problem resolution. Strong computer skills (keyboard proficient, quick data entry with a high level of accuracy). Ability to talk and type. Active Listener Able to work cooperatively with other departments. Multi-task oriented with the ability to prioritize. Detail oriented. Well organized with excellent follow up skills. Ability to handle stressful situations and can easily adapt to change. There are additional competencies linked to individual contributor, provider and leadership roles. Please consult with your leader to discuss additional competencies that are relevant to your position. This position is not eligible for immigration sponsorship. We are an equal opportunity/affirmative action employer. Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact ***************************** Do you have a question about careers at Martin's Point Health Care? Contact us at: *****************************

Job Responsibilities and Requirements The Claims Examiner will act as a liaison between client, employee and healthcare provider. In this position, you are responsible for applying appropriate claims management by providing reliable and responsive service to claimants and clients. Description of responsibilities: Investigates claim issues providing resolution within departmental and regulatory guidelines. Interprets and administers contract provisions: eligibility and duration Accurately codes all system fields with correct financial, diagnosis and duration information. Coordinates with other departments to ensure appropriate claims transition or facilitate timely return to work. Adheres to compliance, departmental procedures, and Unfair Claims Practice regulations. Makes determinations to approve, deny or delay and or reach out to additional resources for review, based on medical certification review and management. Determines the duration associated with the leave and or disability based on the information given by the healthcare provider. Process medium to high complexity or technically difficult claims. Develops and manages claims thought well developed action plans; continues to work the action plan to bring the claim to an appropriate and timely resolution. Actively contributes to customer service, quality and performance objectives. Proactively engages in departmental training to remain current with all claim management practices. Responsible for managing Performance Guarantee clients and meet targeted metrics. Responsible and accountable for maintaining and protecting personal health information. Must maintain a high level of confidentiality and abide by HIPPA rules and regulations. Qualifications: High School Diploma or GED (Bachelor's preferred) Ability to develop proficiency regarding required RSL products, systems and processes related to the effective delivery of new business proposals Microsoft Office experience Attention to detail, analytical skills, and the ability to collaborate with others and work independently Strong organizational skills, including the ability to prioritize work and multi-task Customer service experience and orientation Written and verbal communication skills. The expected hiring range for this position is $23.24 - $29.04 hourly for work performed in the primary location (South Portland, ME). This expected hiring range covers only base pay and excludes any other compensation components such as commissions or incentive awards. The successful candidate's starting base pay will be based on several factors including work location, job-related skills, experience, qualifications, and market conditions. These ranges may be modified in the future. Work location may be flexible if approved by the Company. What We Offer At Reliance Matrix, we believe that fostering an inclusive culture allows us to realize more of our potential. And we can't do this without our most important asset-you. That is why we offer a competitive pay package and a range of benefits to help team members thrive in their financial, physical, and mental wellbeing. Our Benefits: An annual performance bonus for all team members Generous 401(k) company match that is immediately vested A choice of three medical plans (that include prescription drug coverage) to suit your unique needs. For High Deductible Health Plan enrollees, a company contribution to your Health Savings Account Multiple options for dental and vision coverage Company provided Life & Disability Insurance to ensure financial protection when you need it most Family friendly benefits including Paid Parental Leave & Adoption Assistance Hybrid work arrangements for eligible roles Tuition Reimbursement and Continuing Professional Education Paid Time Off - new hires start with at least 20 days of PTO per year in addition to nine company paid holidays. As you grow with us, your PTO may increase based on your level within the company and years of service. Volunteer days, community partnerships, and Employee Assistance Program Ability to connect with colleagues around the country through our Employee Resource Group program Our Values: Integrity Empowerment Compassion Collaboration Fun EEO Statement Reliance Matrix is an equal opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, national origin, citizenship, age or disability, or any other classification or characteristic protected by federal or state law or regulation. We assure you that your opportunity for employment depends solely on your qualifications. #LI-Hybrid #LI-MR1