Claim processor jobs in South Charleston, WV

This job is a non-clinical resource that coordinates, analyzes, and interprets the benefits and claims processes for clinical teams and serves as a liaison between various departments across the enterprise, including but not limited to, Clinical Strategy, Sales/Client Management, Customer Service, Claims, and Medical Policy. The person in this position must fully understand all product offerings available to Organization members and be versed in claims payment methodologies, benefits administration, and business process requirements. **ESSENTIAL RESPONSIBILITIES** + Coordinate, analyze, and interpret the benefits and claims processes for the department. + Serve as the liaison between the department and the claims processing departments to facilitate care/case management activities and special handling claims. Communicate benefit explanations clearly and concisely to all pertinent parties. + Investigate benefit/claim information and provide technical guidance to clinical and claims staff regarding the final adjudication of complex claims. Research and investigate conflicting benefit structures in multi-payor situations. + Provide prompt, thorough and courteous replies to written, electronic and telephonic inquiries from internal/external customers (e.g., clinical, sales/marketing, providers, vendors, etc.) Follow-up on all inquiries in accordance with corporate and regulatory standards and timeframes. + Must have the ability to apply knowledge about the business operations of the area within the defined scope of the job. Assess benefit limitations in accordance with Medical Policy Guidelines. + Monitor and identify claim processing inaccuracies. Bring trends to the attention of management. + Assist with handling inbound calls and strive to resolve customer concerns received via telephone or written communication. + Work independently of support, frequently utilizing resources to resolve customer inquiries. + Collaborate with Clinical Strategy, Sales/Client Management and other areas across the enterprise to respond to client questions and concerns about care/case management and high-cost claimants. + Gather information and develop presentation/training materials for support and education. + Other duties as assigned or requested. **EDUCATION** **Required** + High School or GED **Substitutions** + None **Preferred** + Associate's degree in or equivalent training in Business or a related field **EXPERIENCE** **Required** + 3 years of customer service, health insurance benefits and claims experience. + Working knowledge of Highmark products, systems (e.g., customer service and clinical platforms, knowledge resources, etc.), operations and medical policies + PC Proficiency including Microsoft Office Products + Ability to communicate effectively in both verbal and written form with all levels of employees **Preferred** + Working knowledge of medical procedures and terminology. + Complex claim workflow analysis and adjudication. + ICD9, CPT, HPCPS coding knowledge/experience. + Knowledge of Medicare and Medicaid policies **LICENSES or CERTIFICATIONS** **Required** + None **Preferred** + None **SKILLS** + Knowledge of principles and processes for providing customer service. This includes customer needs assessment, meeting quality standards for services + Knowledge of administrative and clerical procedures and systems such as managing files and records, designing forms and other office procedures + The ability to take direction, to navigate through multiple systems simultaneously + The ability to interact well with peers, supervisors and customers + Understanding the implications of new information for both current and future problem-solving and decision-making + Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate and not interrupting at inappropriate times + Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems + Ability to solve complex issues on multiple levels. + Ability to solve problems independently and creatively. + Ability to handle many tasks simultaneously and respond to customers and their issues promptly. **Language (Other than English):** None **Travel Requirement:** 0% - 25% **PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS** **Position Type** Office-based Teaches / trains others regularly Occasionally Travel regularly from the office to various work sites or from site-to-site Rarely Works primarily out-of-the office selling products/services (sales employees) Never Physical work site required Yes Lifting: up to 10 pounds Constantly Lifting: 10 to 25 pounds Occasionally Lifting: 25 to 50 pounds Rarely **_Disclaimer:_** _The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job._ **_Compliance Requirement_** _: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies._ _As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy._ _Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements._ **Pay Range Minimum:** $21.53 **Pay Range Maximum:** $32.30 _Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets._ Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law. We endeavor to make this site accessible to any and all users. 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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.

How You Will Contribute Investigate, evaluate, and resolve casualty claims in accordance with company policies and applicable laws. Determine coverage, liability, and damages through thorough analysis and documentation. Communicate effectively with policyholders, claimants, attorneys, and other stakeholders. Maintain accurate and timely claim files and documentation. Collaborate with internal teams to ensure efficient claim resolution. Negotiate Auto Material Damage and other Property Damage claims as a result of liability related to the Casualty Claim file. What You Bring to the Table Strong working knowledge of policy language and interpretation. Expertise in claims settlement principles and practices. Familiarity with medical technology, law, repair techniques, and auto estimating. Clear and concise communication skills, both written and oral. Planning and organizational skills. Ability to analyze situations, solve problems, and make decisions. Proficiency with computers and current technology. Excellent communication skills, capable of testifying by deposition and trial if required. Strong negotiation skills. Eagerness to adapt and learn new technology. Your Background Bachelor's degree or equivalent experience. Minimum of 3 years of experience in handling casualty claims. Successful completion of IIA and/or AIC program studies. Working towards, or completion of, CPCU designation. About Celina Insurance Group Celina Insurance Group is a regional Property & Casualty insurer specializing in Commercial, Farm, and Personal Lines insurance. We have over 400 independent agents in Ohio, Indiana, Tennessee, Kentucky, and West Virginia. Since 1914, Celina has been committed to investing in local communities. We are looking for individuals with positive attitudes to join our team and contribute to our ongoing success.

At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. **Position Summary** Review and adjust SF (self-funded), FI (fully insured), Reinsurance, and/or RX claims; adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines. Process provider refunds and returned checks. May handle customer service inquiries and problems. + Perform adjustments across all dollar amount level on customer service platforms by using technical and claims processing expertise. + Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process. + Performs claim re-work calculations. + Follow through completion of claim overpayments, underpayments, and any other irregularities. + Process complex non-routine Provider Refunds and Returned Checks. + Review and interpret medical contract language using provider contracts to confirm whether a claim is overpaid to allocate refund checks. + Handle telephone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals. + Ensures all compliance requirements are satisfied and that all payments are made following company practices and procedures. + Review and handle relevant correspondences assigned to the team that may result in adjustment to claims. + May provide job shadowing to lesser experience staff. + Utilize all resource materials to manage job responsibilities. **Required Qualifications** + 2+ years medical claim processing experience. + Experience in a production environment. + Demonstrated ability to handle multiple assignments competently, accurately, and efficiently. + Effective communications, organizational, and interpersonal skills. **Preferred Qualifications** + DG system claims processing experience. + Associate degree preferred. **Education** + High School Diploma or GED. **Anticipated Weekly Hours** 40 **Time Type** Full time **Pay Range** The typical pay range for this role is: $18.50 - $42.35 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. **Great benefits for great people** We take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: + **Affordable medical plan options,** a **401(k) plan** (including matching company contributions), and an **employee stock purchase plan** . + **No-cost programs for all colleagues** including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. + **Benefit solutions that address the different needs and preferences of our colleagues** including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit ***************************************** We anticipate the application window for this opening will close on: 12/23/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

Under the direction of the Manager of Claims, the reviewer performs initial review of claims, including HCFA 1500 and UB 04 claims. Reviewer must meet or exceed production and quality standards and follow documented policies and procedures. Required: High school diploma or equivalent. Ability to follow written directions and work independently. Familiarity with medical terminology, CPT and ICD-10 coding is required. Computer and typing experience is required. Desired: Previous claims processing. Experience in billing or physician office experience is preferred. Responsibilities: Performs initial review of all claim edits as directed. Completes or routes all reviews in accordance with time parameters established by The Health Plan. Reviews each claim flag in sequence, totally completing one at a time in accordance with established criteria/payment guidelines. Reports patterns of incorrect billing and utilization to manager or claims coordinator. Advises management of items that are unclear or that are not addressed in the established criteria/payment guidelines. Maintain a quality rating of 98%. Processes 15-20 claims per hour. Consistently displays a positive attitude and acceptable attendance. Participate in external and/or internal trainings as requested. Equal Opportunity Employer The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.

Come to work with us at Community Health Services! We offer full-time benefits, 10 paid holidays, no weekend hours and so much more! We are looking for a full-time Claims Specialist to work in our Fremont office. CHS employs those who are eager to grow professionally, gain great experience, and work with a terrific team. The Claims Specialist will be responsible for performing general finance functions, entering encounters, processing and recording claims and all other duties as assigned. Hours for this position are: Mondays 7am-7pm, Tuesdays through Thursdays 8am-5pm, Fridays 8am-1pm Qualified candidates must have the following to be considered for employment: * Associate's degree from an accredited college or university * Experience in accounting/bookkeeping * Demonstrates ability to organize and implement general accounting and bookkeeping procedures for a healthcare organization * Ability to work with clinic personnel and patients in a courteous, cooperative manner * Ability to function as part of a team * Must have excellent customer service skills * Must have excellent multi-tasking, problem solving, and decision-making skills * Ability to follow instructions with attention to detail * Demonstrates professional relationship skills, and a strong work ethic * Prioritizes responsibilities, takes initiative, and possesses excellent organizational skills * Demonstrates effective communication skills * Ability to work with a culturally diverse group of people At CHS, we value our team and the critical role they play in patient care. If you're dependable, detail-oriented, and passionate about making a difference in your community, we'd love to hear from you. CHS is a drug-free/nicotine free organization. Candidates must pass a drug and nicotine screening upon employment offer.

Sign On Bonus: $1,000 Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law This position is not eligible for employment based sponsorship. Ensures accurate adjudication of claims, by translating medical policies, reimbursement policies, and clinical editing policies into effective and accurate reimbursement criteria. PRIMARY DUTIES: * Review medical record documentation in support of Evaluation and Management, CPT, HCPCS and ICD-10 code. * Reviews company specific, CMS specific, and competitor specific medical policies, reimbursement policies, and editing rules, as well as conducting clinical research, data analysis, and identification of legislative mandates to support draft development and/or revision of enterprise reimbursement policy. * Translates medical policies into reimbursement rules. * Performs CPT/HCPCS code and fee schedule updates, analyzing each new code for coverage, policy, reimbursement development, and implications for system edits. * Coordinates research and responds to system inquiries and appeals. * Conducts research of claims systems and system edits to identify adjudication issues and to audit claims adjudication for accuracy. * Perform pre-adjudication claims reviews to ensure proper coding was used. * Prepares correspondence to providers regarding coding and fee schedule updates. * Trains customer service staff on system issues. * Works with providers contracting staff when new/modified reimbursement contracts are needed. Minimum Requirements: Requires a BA/BS degree and a minimum of 2 years related experience; or any combination of education and experience, which would provide an equivalent background. Certified Professional Coder (CPC) or Registered Health Information Administrator (RHIA) certification required. Preferred Skills, Capabilities and Experience: * CEMC, RHIT, CCS, CCS-P certifications preferred. Job Level: Non-Management Exempt Workshift: Job Family: MED > Licensed/Certified - Other Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ******************************************** for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Delta Dental of Kentucky is looking for a dynamic individual to fill the role of Benefit Specialist in our Louisville, Kentucky office. Job Summary: To analyze and adjudicate dental claims while working in a variety of areas. Provide support within the Claims department and across the organization in resolving claims related issues. Primary Job Responsibilities: Administer, analyze, adjudicate and process claims in accordance with benefit contracts and plan policies; assist department to resolve claim issues; maintain claim records. Work closely with other departments for inquiries regarding claims processed. Cross-train on various queues and jobs to allow for coverage when other staff members are out of the office. Perform coding and resolution of pending claims to meet or exceed department production standards. Provide character correction of claims or other documents submitted from customers or providers into our processing system. Manually enter claims on a limited basis. Review claims for proper documentation and route to Dental Consultants for review based on the procedures submitted. Work directly with the Dental Consultant to resolve issues and determine benefit. Mail letters with incomplete addresses to dentists and members for additional information. Determine documentation required if there is need for additional information. Maintain required production and quality standards established by the department and contribute to the accomplishment of team goals. Provide dental expertise and/or interpretation of dental policies, procedures codes, and processing guidelines to internal and external contacts. Recommend policy changes for the department. Receive and create an adjustment to indicate money is credited back to the claim; types of adjustments performed are corrections, void/stop payment, full refunds, partial refunds, adjust/no pay and reissues, and special check requests when necessary. Perform other related assigned duties as necessary to complete the Primary Job Responsibilities as described above. Minimum Qualifications: Position requires a high school diploma or equivalent. Three years' experience working in a medical or dental related claims position preferred. Dental assistant training or certification and/or related dental office experience a plus. Will accept any suitable combination of education, training, or experience. Position requires intermediate PC keyboarding and Microsoft Windows-based programs, and candidate must meet the company's PC testing standards to be considered. Strong communication skills and the ability to learn and access different queues to allow work in a variety of queues at one time throughout the workday required. Delta Dental of Kentucky, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, gender identity, national origin, or veteran status.

Job Description An Account Resolution Specialist I is responsible for researching and identifying unpaid, partially paid, incorrectly paid or denied claims. They must follow-up with insurance carriers verbally or via on-line tools and properly discuss the problem with the knowledge of how to negotiate payment/additional payments on all claims. In the event the needs arise, they will also resubmit a corrected claim and/or follow-up with patients regarding the issue(s) as needed. Minimum Education Must have a high-school diploma or a GED. Minimum Work Experience No prior work experience in this related field is required at this level. Required Skills Customer service Must have general Microsoft Office (Word, Excel, PPT, and Outlook) experience. Ability to manage their time in order to meet job requirements. Ability to review an account and come to a decision as to what the proper solution would be to resolve the account. Must be a team player. Screening Requirements: Drug Screen Tuberculosis Test Background Check Physical Exam Respirator Fit Eligible Benefits: Medical, Dental and Vision *Excellent Low Premiums!*- No copays or Deductibles when utilizing MCCH services! Life Insurance *ZERO premium* Retirement Plan Paid Time Off Bereavement Bridge Coverage *ZERO premium for self-coverage when enrolled in medical coverage Tuition Reimbursement Our Mission: To improve the lives of those we serve by providing outstanding care and services through our confident, compassionate and exceptional healthcare professionals. Our Vision: To be chosen by our community and expanded service region based on proven outcomes as the trusted provider to care for their families, friends and neighbors. Our Values: Competence, Excellence, Compassion, Respect and Integrity.

Claim Specialist needed to combat rising healthcare costs and empower health plans! The Phia Group is a service-oriented consultant that assists health plans nationwide. We provide our clients with innovative cost-cutting solutions and innovative service offerings. We continue to enjoy growth thanks to our most valuable resource our talented and committed team. Until recently, surprise medical bills were a leading cause of financial distress and bankruptcy for American families. Surprise billing occurs when a patient presents to an out-of-network medical provider through no fault of their own like in the case of an emergency and the patient becomes responsible for amounts beyond what their insurance pays. Thankfully, beginning in 2022 with the implementation of the No Surprises Act , the legislature effectively banned surprise billing, instead prescribing a system of negotiation and arbitration that health plans and providers must follow to resolve billing disputes. The Claims Specialist will be responsible for supporting the team on all aspects of the No Surprises Act, including reviewing medical claims, keeping track of strict deadlines, drafting settlement agreements, and preparing submissions for Independent Dispute Resolution, among many other tasks. The candidate will also be expected to support the team on balance billing and overpayment matters as needed. This position requires someone that is proactive, persuasive, persistent, respectful, and assertive. The candidate must be comfortable multi-tasking and possess strong communication skills, both oral and written. The Phia Group is growing quickly and so the candidate must be comfortable in a dynamic fast-paced environment. Essential Duties and Responsibilities include the following. Other duties may be assigned. Manage a daily running inventory of unpaid claims or claim disputes. Review and prioritize claims based on processing criteria, timelines, client demands, and service level standards. Contact facilities and providers to discuss charge adjustments and rationale. Contact facilities and explain benefits to resolve payment disputes. Draft correspondence pertaining to settlement and negotiation efforts for providers and other entities. Capture detailed notes on calls for future reference. As needed, handle member inquires in accordance to their medical plan. Work with The Phia Group s legal department to ensure escalation of claims. Participate in on-going process improvement to develop efficiencies that streamline the claim settlement process. Ability to properly handle confidential information in accordance with the Health Insurance Portability and Accountability Act (HIPAA). Experience and Qualifications Preferred: Baccalaureate degree (BA/BS) from an accredited college or university. Preferred: Experience in a medical healthcare claims role, preferably involving negotiation, or experience at an insurance company, TPA, or hospital, preferably with emphasis in claims, fee schedules, or contracting. Computer literate, including Microsoft Office products. Working Conditions / Physical Demands Sitting at workstation for prolong periods of time. Extensive computer work. Workstation may be exposed to overhead fluorescent lighting and air conditioning. Fast paced work environment. Operates office equipment including personal computer, copiers, and fax machines. This job description is not intended to be and should not be construed as an all-inclusive list of all the responsibilities, skills or working conditions associated with the position. While it is intended to accurately reflect the position activities and requirements, the company reserves the right to modify, add or remove duties and assign other duties as necessary. External and internal applicants, as well as position incumbents who become disabled as defined under the Americans with Disabilities Act, must be able to perform the essential job functions (as listed here) either unaided or with the assistance of a reasonable accommodation to be determined by management on a case by case basis. Salary: $50,000 - $65,000 / year

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

Top 100 Agency for 2025 Best Agencies to Work for in 2024 by the Insurance Journal Big “I” Best Practices Agency in 2023 Annual bonus eligibility No weekends required - great work/life balance 3+ weeks of Paid Time Off 8 Paid Company Holidays We are looking for someone who will Manage the claims reporting process for agency clients. Report claims to the appropriate carrier and maintain records in the agency management system by documenting claim actions in accordance with established procedures. Follow up on claim to obtain the specific adjuster and claim number relevant to the reported loss. Notify appropriate parties when a claim is processed with carrier, providing accurate and timely claim information. Continuously monitor claims until claims are closed by the insurance carrier. Report any potential issues with a claim to the client's Account Manager and Producer, escalating to management as needed. Prepare reports by collecting and summarizing information as requested by management. Why Join AAA Club Alliance and the Energy Insurance team? A base rate of $20.00 to $25.00/hour, depending on experience and geographic location. Annual bonus potential Do you have what it takes? Minimum of 2 years experience handling claims for Commercial Insurance - general liability, workers compensation, commercial auto, etc. Strong communication skills (both verbal and written) and attention to detail Strong time management skills Ability to obtain property and casualty license within 60 days of hire Full time Associates are offered a comprehensive benefits package that includes: Medical, Dental, and Vision plan options Up to 2 weeks Paid parental leave 401k plan with company match up to 7% 2+ weeks of PTO within your first year Paid company holidays Company provided volunteer opportunities + 1 volunteer day per year Free AAA Membership Continual learning reimbursement up to $5,250 per year And MORE! Check out our Benefits Page for more information ACA is an equal opportunity employer and complies with all applicable federal, state, and local employment practices laws. At ACA, we are committed to cultivating a welcoming and inclusive workplace of team members with diverse backgrounds and experiences to enable us to meet our goals and support our values while serving our Members and customers. We strive to attract and retain candidates with a passion for their work and we encourage all qualified individuals to apply. It is ACA's policy to employ the best qualified individuals available for all positions. Hiring decisions are based upon ACA's operating needs, and applicant qualifications including, but not limited to, experience, skills, ability, availability, cooperation, and job performance. Job Category: Insurance

* Top 100 Agency for 2025 * Best Agencies to Work for in 2024 by the Insurance Journal * Big "I" Best Practices Agency in 2023 * Annual bonus eligibility * No weekends required - great work/life balance * 3+ weeks of Paid Time Off * 8 Paid Company Holidays We are looking for someone who will * Manage the claims reporting process for agency clients. * Report claims to the appropriate carrier and maintain records in the agency management system by documenting claim actions in accordance with established procedures. * Follow up on claim to obtain the specific adjuster and claim number relevant to the reported loss. Notify appropriate parties when a claim is processed with carrier, providing accurate and timely claim information. * Continuously monitor claims until claims are closed by the insurance carrier. Report any potential issues with a claim to the client's Account Manager and Producer, escalating to management as needed. * Prepare reports by collecting and summarizing information as requested by management. Why Join AAA Club Alliance and the Energy Insurance team? * A base rate of $20.00 to $25.00/hour, depending on experience and geographic location. * Annual bonus potential Do you have what it takes? * Minimum of 2 years experience handling claims for Commercial Insurance - general liability, workers compensation, commercial auto, etc. * Strong communication skills (both verbal and written) and attention to detail * Strong time management skills * Ability to obtain property and casualty license within 60 days of hire Full time Associates are offered a comprehensive benefits package that includes: * Medical, Dental, and Vision plan options * Up to 2 weeks Paid parental leave * 401k plan with company match up to 7% * 2+ weeks of PTO within your first year * Paid company holidays * Company provided volunteer opportunities + 1 volunteer day per year * Free AAA Membership * Continual learning reimbursement up to $5,250 per year * And MORE! Check out our Benefits Page for more information ACA is an equal opportunity employer and complies with all applicable federal, state, and local employment practices laws. At ACA, we are committed to cultivating a welcoming and inclusive workplace of team members with diverse backgrounds and experiences to enable us to meet our goals and support our values while serving our Members and customers. We strive to attract and retain candidates with a passion for their work and we encourage all qualified individuals to apply. It is ACA's policy to employ the best qualified individuals available for all positions. Hiring decisions are based upon ACA's operating needs, and applicant qualifications including, but not limited to, experience, skills, ability, availability, cooperation, and job performance. Job Category: Insurance

Claims Specialist needs 1 year claims system experience, preferably in the Healthcare industry Claims Specialist requires: College degree or equivalent experience required Minimum of 1 year claims system experience, preferably in the Healthcare industry Basic analytical and problem solving skills Good communication and interpersonal skills Ability to work independently and with others Ability to manage more than one assigned tasks at the same time Claims Specialist duties: Responsible for setting up new Managed Care groups in the claims system Responsible for fulfilling requested revisions to existing Managed Care group in the claims system (except Reseller product changes) Responsible for creating standard products in the system (using the Product Key Sheet method) Responsible for performing audits on client setup or maintenance requests (excludes complex product configuration requests) Follow the established corporate and industry audit controls (i.e. SOX, SSAE 18, etc.) when fulfilling setup and maintenance requests Resolve client structure setup questions/issues sent to the team with minimal supervisor guidance Maintain relationships with Implementation Managers and Account Managers to facilitate fulfillment of implementation questions and requests in a timely manner

Job DescriptionService Wire Company, a premier supplier of industrial and utility wire and cable, is currently seeking a Customer Quality and Claims Specialist in Culloden, WV. If you are looking to join a great organization and a chance to become a part of our growing team, this may be the opportunity for you! Position Summary:The Customer Quality and Claims Specialist supports internal and external customers by managing product claims, returns, and quality related inquiries. The role investigates issues, coordinates resolutions across departments, and ensures timely, accurate, and professional communication while recommending process improvements to prevent future claims.Tasks/Duties/Responsibilities: Monitor and manage customer cases, proactively addressing delays Investigate and resolve product claims, pricing adjustments, and deductions in coordination with Sales, Shipping and Quality Control Analyze customer complaints to determine root cause, corrective actions, and preventive measures Communicate findings, resolutions, and recommendations to customers and internal stakeholders Manage freight claim by providing raw material scrap values and re-claimed materials while tracking the funds received Check records, such as bills, computer printouts, and related documents and correspondence, and converse or correspond with customer and other company personnel, such as sales, shipping, engineering, and credit, to obtain facts regarding customer complaint Notify customer and designated personnel of findings, adjustments, and recommendations, such as exchange of merchandise Recommend improvements in product, packaging, shipping methods, service, or billing processes to minimize future claims. Perform additional duties as assigned Knowledge/Skills/Requirements: High school diploma or equivalent; 2-year degree preferred Strong research, documentation, and analytical skills Proficient with Microsoft Office Solid basic math skills Ability to multi-task, prioritize, and manage time effectively Strong written and oral communication skills Ability to effectively interact with internal and external customers Ability to travel from time to time (less than 10%) Familiarity with office equipment including printers, copiers, scanners etc. Reports To: Quality Assurance Manager

By joining Sedgwick, you'll be part of something truly meaningful. It's what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there's no limit to what you can achieve. Newsweek Recognizes Sedgwick as America's Greatest Workplaces National Top Companies Certified as a Great Place to Work Fortune Best Workplaces in Financial Services & Insurance Claims Representative (IAP) - Workers Compensation Training Program Are you looking for an impactful job requiring no prior experience that offers an opportunity to develop a professional career? + A stable and consistent work environment in an office setting. + A training program to learn how to help employees and customers from some of the world's most reputable brands. + An assigned mentor and manager who will guide you on your career journey. + Career development and promotional growth opportunities through increasing responsibilities. + A diverse and comprehensive benefits package to take care of your mental, physical, financial and professional needs. **PRIMARY PURPOSE OF THE ROLE:** To be oriented and trained as new industry professional with the ability to analyze workers compensation claims and determine benefits due. **ARE YOU AN IDEAL CANDIDATE?** We are seeking enthusiastic individuals for an entry-level trainee position. This role begins with a comprehensive 6-week classroom-based professional training program designed to equip you with the foundational skills needed for a successful career in claims adjusting. Over the course of a few years, you'll have the opportunity to grow and advance within the field. **ESSENTIAL RESPONSIBLITIES MAY INCLUDE** + Attendance and completion of designated classroom claims professional training program. + Performs on-the-job training activities including: + Adjusting lost-time workers compensation claims under close supervision. May be assigned medical only claims. + Adjusting low and mid-level liability and/or physical damage claims under close supervision. + Processing disability claims of minimal disability duration under close supervision. + Documenting claims files and properly coding claim activity. + Communicating claim action/processing with claimant and client. + Supporting other claims examiners and claims supervisors with larger or more complex claims as assigned. + Participates in rotational assignments to provide temporary support for office needs. **QUALIFICATIONS** Bachelor's or Associate's degree from an accredited college or university preferred. **EXPERIENCE** Prior education, experience, or knowledge of: - Customer Service - Data Entry - Medical Terminology (preferred) - Computer Recordkeeping programs (preferred) - Prior claims experience (preferred) Additional helpful experience: - State license if required (SIP, Property and Liability, Disability, etc.) - WCCA/WCCP or similar designations - For internal colleagues, completion of the Sedgwick Claims Progression Program **TAKING CARE OF YOU** + Entry-level colleagues are offered a world class training program with a comprehensive curriculum + An assigned mentor and manager that will support and guide you on your career journey + Career development and promotional growth opportunities + A diverse and comprehensive benefits offering including medical, dental vision, 401K, PTO and more _As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is 25.65/hr. A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits. #claims #claimsexaminer #entrylevel #remote #LI-Remote_ Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace. **If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.** **Sedgwick is the world's leading risk and claims administration partner, which helps clients thrive by navigating the unexpected. The company's expertise, combined with the most advanced AI-enabled technology available, sets the standard for solutions in claims administration, loss adjusting, benefits administration, and product recall. With over 33,000 colleagues and 10,000 clients across 80 countries, Sedgwick provides unmatched perspective, caring that counts, and solutions for the rapidly changing and complex risk landscape. For more, see** **sedgwick.com**

Job Summary: The Claim Review Specialist is responsible for entering, reviewing, and proactively managing workers' compensation claims, including gathering medical and claim information, communicating with employers, providers, injured workers, and the BWC, and supporting early return-to-work efforts. This role requires strong attention to detail, confidentiality, customer service skills, and the ability to manage high call volumes while meeting quality and productivity standards. Principal Duties & Responsibilities: Reports directly to the Claim Review Specialist Team Leader. Enter and process initial claims in UniSource, complete initial and/or follow-up calls to employer, provider, IW, and BWC as appropriate while documenting the results of gathered information. Additionally, responsible for complete follow-up on claims, resulting in transition to the Return to Work Specialist or case closure as appropriate, including gathering any additional information on RTW, missing claims master fields, continued treatment, etc. Gather complete information on all mandatory UniSource system field requirements to ensure accurate transmission to the BWC. Gather all initial and subsequent medical documentation necessary to process potential claim updates. Assist in identifying RAW and Onsite Therapy candidates where appropriate. Proactive claims management, early RTW intervention, and transfer of claims to Return to Work Specialist for continued RTW management when appropriate. Assists other Claim Review Specialists on the team. Answering incoming and making outgoing phone calls. Provide excellent customer service to all internal and external customers. Required to meet team quality and productivity standards. Maintain and develop teamwork within all departments of UniComp. Other duties as assigned by Management. Maintain and exhibit Sheakley Core Values. Qualifications: Knowledge and skills at a level normally acquired through the completion of High School education or equivalent. Typing 50-60 WPM Ability to handle sensitive information and maintain a high level of confidentiality. Proficiency in Microsoft Office products including Word, Excel, Outlook, etc. Medical Terminology or equivalent experience. Previous customer service experience preferred. Requirements: Attention to detail, flexibility, and strong ability to multi-task. Problem solving ability. Physical and Mental Demands: Ability to sit for prolonged period of time. Ability to answer high call volume while maintaining accurate system notes. This job description is not intended to be all inclusive and the employee will also perform other reasonably related business duties as assigned by the immediate supervisor and other management as required. EQUAL OPPORTUNITY POLICY: It is our policy to seek and employ the best qualified personnel and to provide equal opportunity for the advancement of employees, including upgrading, promoting and training and to administer these activities in a manner which will not discriminate against any person because of race, color, religion, age, sex, marital status, national origin, disability or any other basis prohibited by law.

To ensure procurement of accurate pre-certification authorization/referral for applicable returning and new patients as well as review and completion of accurate, complete patient charts. Scheduling of multiple physician ordered tests, exams and surgeries where applicable. Responsibilities * Daily review of charts to determine if pre-certification/pre-authorization or referrals are needed. • Review specific patient insurance info to determine medical necessity requirements for specific treatments. • Correspond with medicare and various insurance companies to facilitate obtaining pertinent data on compliance, authorizations, verifications, progress notes, medical necessity guidelines and precertification and pre-authorization requirements. • Perform clerical duties as necessary, including composing letters to patients, insurance carriers and referring physicians regarding any issues. • Per physician order, schedule patient surgery and communicate all necessary information to the appropriate parties. • Make subsequent referrals to other physicians per physician review of test/scan results. • Establish new patient account in billing software upon receiving referral from physician. Forward all applicable info to appropriate personnel for inclusion in the medical chart. • Maintain continuing education treatment trends, current medical terminology used in pre-certification, and ICD-10, CPT and HCPCS codes. • Cross train for front desk and medical assistant roles. Provide back up as needed. • Schedule all procedures, collect, apply and deposit all funds. Knowledge, Skills & Abilities Patient Group Knowledge (Only applies to positions with direct patient contact) The employee must possess/obtain (by the end of the orientation period) and demonstrate the knowledge and skills necessary to provide developmentally appropriate assessment, treatment or care as defined by the department's identified patient ages. Specifically the employee must be able to demonstrate competency in: 1) ability to obtain and interpret information in terms of patient needs; 2) knowledge of growth and development; and 3) understanding of the range of treatment needed by the patients. Competency Statement Must demonstrate competency through an initial orientation and ongoing competency validation to independently perform tasks and additional duties as specified in the job description and the unit/department specific competency checklist. Common Duties and Responsibilities (Essential duties common to all positions) 1. Maintain and document all applicable required education. 2. Demonstrate positive customer service and co-worker relations. 3. Comply with the company's attendance policy. 4. Participate in the continuous, quality improvement activities of the department and institution. 5. Perform work in a cost effective manner. 6. Perform work in accordance with all departmental pay practices and scheduling policies, including but not limited to, overtime, various shift work, and on-call situations. 7. Perform work in alignment with the overall mission and strategic plan of the organization. 8. Follow organizational and departmental policies and procedures, as applicable. 9. Perform related duties as assigned. Education * High School Diploma or GED Credentials * No Certification, Competency or License Required Work Schedule: Days Status: Full Time Regular 1.0 Location: Heart & Vascular Center Location of Job: US:WV:Charleston Talent Acquisition Specialist: Tamara B. Young ******************************

We are seeking a Pharmacy Adjudication Specialist at our Specialty pharmacy in Louisville, KY. This will be a Full-Time position. This position must be located within driving distance to our pharmacy, with a hybrid work style. Onco360 Pharmacy is a unique oncology pharmacy model created to serve the needs of community, oncology and hematology physicians, patients, payers, and manufacturers. Starting salary from $20.00 an hour and up Sign-On Bonus: $5,000 for employees starting before February 1, 2026. We offer a variety of benefits including: Medical; Dental; Vision 401k with a match Paid Time Off and Paid Holidays Tuition Reimbursement Company paid benefits - life; and short and long-term disability Pharmacy Adjudication Specialist Major Responsibilities: The Pharmacy Adjudication Specialist will adjudicate pharmacy claims, review claim responses for accuracy. ensure prescription claims are adjudicated correctly according to the coordination of benefits, resolve any third-party rejections, obtain overrides if appropriate, and be responsible for patient outreach notification regarding any delay in medication delivery due to insurance claim rejections Pharmacy Adjudication Specialists at Onco360... Practices first call resolution to help health care providers and patients with their pharmacy needs, answering questions and requests. Provides thorough, accurate and timely responses to requests from pharmacy operations, providers and/or patients regarding active claims information.. Ensures complete and accurate patient setup in CPR+ system including patient demographic and insurance information. Adjudicates pharmacy claims for prescriptions in active workflow for primary, secondary, and tertiary pharmacy plans and reviews claim responses for accuracy before accepting the claim. Contacts insurance companies to resolve third-party rejections and ensures pharmacy claim rejections are resolved to allow for timely shipping of medications. Performs outreach calls to patients or providers to reschedule their medication deliveries if claim resolution cannot be completed by ship date and causes shipment delays Ensures copay cards are only applied to claims for eligible patients based on set criteria such as insurance type (Government beneficiaries not eligible) Manages all funding related adjudications and works as a liaison to Onco360 Advocate team. Assists pharmacy team with all management of electronically adjudicated claims to ensure all prescription delivery assessments are reconciled and copay payments are charged prior to shipment. Serves as customer service liaison to patients regarding financial responsibility prior to shipments, contacts patients to communicate any copay discrepancy between quoted amount and claim and collects payment if applicable. Document and submit requests for Patient Refunds when appropriate. Pharmacy Adjudication Specialist Qualifications and Responsibilities... Education/Learning Experience Required: High School Diploma or GED. Previous Experience in Pharmacy, Medical Billing, or Benefits Verification, Pharmacy Claims Adjudication Desired: Associate degree or equivalent program from a 2 year program or technical school, Certified Pharmacy Technician, Specialty pharmacy experience Work Experience Required: 1+ years experience in Pharmacy/Healthcare Setting or pharmacy claims experience Desired: 3+ years experience in Pharmacy/Healthcare Setting or pharmacy claims experience Skills/Knowledge Required: Pharmacy/NDC medication billing, Pharmacy claims resolution, PBM and Medical contracts, knowledge/understanding of Medicare, Medicaid, and commercial insurance, NCPDP claim rejection resolution, coordination of benefits, pharmacy or healthcare-related knowledge, knowledge of pharmacy terminology including sig codes, and Roman numerals, brand/generic names of medication, basic math and analytical skills, Intermediate typing/keyboarding skills Desired: Knowledge of Foundation Funding, Specialty pharmacy experience Licenses/Certifications Required: Registration with Board of Pharmacy as required by state law Desired: Certified Pharmacy Technician (PTCB) Behavior Competencies Required: Independent worker, good interpersonal skills, excellent verbal and written communications skills, ability to work independently, work efficiently to meet deadlines and be flexible, detail-oriented, great time-management skills #Company Values: Teamwork, Respect, Integrity, Passion