Claim processor jobs in South Hill, WA - 30 jobs

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. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at ***************************** California Consumer Privacy Act Employees, Contractors, and Applicants Notice Req ID: J273827

Provides analyst support for claims research activities including reviewing and researching claims to ensure regulatory requirements are appropriately applied, identifying root-cause of processing errors through research and analysis, coordinating and engaging with appropriate departments, developing and tracking remediation plans, and monitoring claims reprocessing through resolution. **Essential Job Duties** - Serves as claims subject matter expert - using analytical skills to conduct research and analysis to address issues, requests, and support high-priority claims inquiries and projects. - Interprets and presents in-depth analysis of claims research findings and results to leadership and respective operations teams. - Manages and leads major claims projects of considerable complexity and volume that may be initiated internally, or through provider inquiries/complaints, or legal requests. - Assists with reducing rework by identifying and remediating claims processing issues. - Locates and interprets claims-related regulatory and contractual requirements. - Tailors existing reports and/or available data to meet the needs of claims projects. - Evaluates claims using standard principles and applicable state-specific regulations to identify claims processing errors. - Applies claims processing and technical knowledge to appropriately define a path for short/long-term systematic or operational fixes. - Seeks to improve overall claims performance, and ensure claims are processed accurately and timely. - Identifies claims requiring reprocessing or readjudication in a timely manner to ensure compliance. - Works collaboratively with internal/external stakeholders to define claims requirements. - Recommends updates to claims standard operating procedures (SOPs) and job aids to increase the quality and efficiency of claims processing. - Fields claims questions from the operations team. - Interprets, communicates, and presents, clear in-depth analysis of claims research results, root-cause analysis, remediation plans and fixes, overall progress, and status of impacted claims. - Appropriately conveys claims-related information and tailors communication based on targeted audiences. - Provides sufficient claims information to internal operations teams that communicate externally with providers and/or members. - Collaborates with other functional teams on claims-related projects, and completes tasks within designated/accelerated timelines to minimize provider/member impacts and maintain compliance. - Supports claims department initiatives to improve overall claims function efficiency. **Required Qualifications** - At least 3 years of medical claims processing experience, or equivalent combination of relevant education and experience. - Medical claims processing experience across multiple states, markets, and claim types. - Knowledge of claims processing related to inpatient/outpatient facilities contracted with Medicare, Medicaid, and Marketplace government-sponsored programs. - Data research and analysis skills. - Organizational skills and attention to detail. - Time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines. - Ability to work cross-collaboratively in a highly matrixed organization. - Customer service skills. - Effective verbal and written communication skills. - Microsoft Office suite (including Excel), and applicable software programs proficiency. **Preferred Qualifications** - Health care claims analysis experience. - Project management experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $22.81 - $46.42 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

The Jonus Group is an insurance-only, full-service recruiting firm that offers both direct hire and contract hire services and we are seeking a Washington Workers Compensation Claims professional to join one of our valued client's dynamic and growing team. As a key member of their Claims department, you will not only be responsible for managing their Workers Comp Claims but you will also be a key member of the team in building strong customer relationships, providing strong customer service, and ensuring timely and fair resolution for all parties involved. What's in it for you: $95,000 - $115,000/year based on experience Annual bonus potential based on individual performance and company profit sharing Competitive PTO package 10 Company identified holidays Full benefits available Growth Opportunities Key Responsibilities: Supervise claims staff in daily operations Assist management with recruiting, interviewing, and training new team members Ensure compliance with Workers' Compensation laws and regulatory reporting requirements Promote team performance through ongoing training, coaching, and performance evaluations; recommend merit adjustments for management review Provide technical guidance on complex claims, investigations, litigation, and client-specific requirements Serve as a liaison to resolve claim-related or procedural issues for clients and employees Maintain compliance with HIPAA regulations, policies, and procedures Maintain regular and reliable attendance Follow all safety rules and regulations as part of the Injury and Illness Prevention Program (IIPP) Follow all organizational policies, procedures, and best practices Perform other duties and special projects as assigned Qualifications: 5+ years of experience as a Workers' Compensation Claims Adjuster or Supervisor background within Washington, Oregon, and Alaska Indemnity claims WA Adjuster's license Knowledge of Washington state workers' compensation laws, regulations, and industry practices Proficient in claims management software and Microsoft Office Suite #LI-MW1 #LI-PR1

Marketing Statement: Philadelphia Insurance Companies, a member of the Tokio Marine Group, designs, markets and underwrites commercial property/casualty and professional liability insurance products for select industries. We have been in operation since 1962 and are nationally recognized as a member of Ward's Top 50 and rated A++ by A.M.Best. We are looking for a Claims Supervisor II - Commercial Auto - BI to join our team. Summary: * Supervises claims adjusters and technical support staff to manage the day-to-day handling and settlement of claims, the processing and tracking of documents, making payments, tracking trends and communicating with underwriting. * A typical day will include the following: * Supervises the day-to-day activities of a claims handling unit; oversees the investigation of insurance claims. * Assures that corporate claims handling procedures and priorities are followed and that budget and productivity requirements are met. * Assures that department targets for customer service quality and priorities are met. * Participates in the hiring, training, evaluation and development of the claims staff. Qualifications: * High School Diploma; Bachelor's degree from a four-year college or university preferred. * 10 plus years related experience and/or training; or equivalent combination of education and experience. * Associate in Claims, CPCU or other industry related studies. * Experience with Windows operating system. * Basic Word processing skills. National Range : $112,165.00 - $125,360.00 Ultimate salary offered will be based on factors such as applicant experience and geographic location. PHLY locations considered: Roseville, CA / Seattle, WA / West Linn, OR. EEO Statement: Tokio Marine Group of Companies (including, but not limited to the Philadelphia Insurance Companies, Tokio Marine America, Inc., TMNA Services, LLC, TM Claims Service, Inc. and First Insurance Company of Hawaii, Ltd.) is an Equal Opportunity Employer. In order to remain competitive we must attract, develop, motivate, and retain the most qualified employees regardless of age, color, race, religion, gender, disability, national or ethnic origin, family circumstances, life experiences, marital status, military status, sexual orientation and/or any other status protected by law. Benefits: We offer a comprehensive benefit package, which includes tuition reimbursement and a generous 401K match. Our rich history of outstanding results and growth allow us to focus our business plan on continued growth, new products, people development and internal career opportunities. If you enjoy working in a fast paced work environment with growth potential please apply online. Additional information on Volunteer Benefits, Paid Vacation, Medical Benefits, Educational Incentives, Family Friendly Benefits and Investment Incentives can be found at ***************************************** Share: mail Apply Now

Make a difference with a career in insurance At The Cincinnati Insurance Companies, we put people first and apply the Golden Rule to our daily operations. To put this into action, we're looking for extraordinary people to join our talented team. Our service-oriented, ethical, knowledgeable, caring associates are the heart of our vision to be the best company serving independent agents. We help protect families and businesses as they work to prevent or recover from a loss. Share your talents to help us reach for continued success as we bring value to the communities we serve and demonstrate that Actions Speak Louder in Person. If you're ready to build productive relationships, collaborate within a diverse team, embrace challenges and develop your skills, then Cincinnati may be the place for you. We offer career opportunities where you can contribute and grow. Build your future with us Our Field Claims department is currently seeking field claims representatives to service the territory surrounding: Seattle, Washington. The candidate is required to reside within the territory. This territory allows either an experienced or entry-level representative the opportunity to investigate and evaluate multi-line insurance claims through personal contact to ensure accurate settlements. Be ready to: * complete thorough claim investigations * interview insureds, claimants, and witnesses * consult police and hospital records * evaluate claim facts and policy coverage * inspect property and auto damages and write repair estimates * prepare reports of findings and secure settlements with insureds and claimants * use claims-handling software, company car and mobile applications to adjust loss in a paperless environment * provide superior and professional customer service * once eligible, become a certified and active Arbitration Panelist To be an Entry Level Claims Representative: The pay range for this position is $63,250 - $87,400 annually. The pay determination is based on the applicant's education, experience, location, knowledge, skills and abilities. Eligible associates may also receive an annual cash bonus and stock incentives based on company and individual performance. Be equipped with: * be available and communicative during your regular business hours * a desire to learn about the insurance industry and provide a great customer experience * the ability to work unsupervised * excellent verbal and written communication skills * strong interpersonal skills * excellent problem-solving, negotiation, organizational and prioritization skills * preparedness to follow-up with others in a timely manner * a valid driver's license Bring education or experience from: * a bachelor's degree * AINS, AIC, or CPCU designations preferred Benefits in addition to compensation include: * company car * company stock options, including Restricted Share Units and Incentive based stock options * paid time off (PTO) * 401K with 6% company match To be an Experienced Claims Representative: The pay range for this position is $71,300 - $103,500 annually. The pay determination is based on the applicant's education, experience, location, knowledge, skills and abilities. Eligible associates may also receive an annual cash bonus and stock incentives based on company and individual performance. Be equipped with: * be available and communicative during your regular business hours * multi-line claims experience preferred * ability to completely assess auto, property, and bodily injury type damages * capacity to work unsupervised * excellent verbal and written communication skills * strong interpersonal skills * excellent problem-solving, negotiation, organizational, and prioritization skills * preparedness to follow-up with others in a timely manner * a valid driver's license Bring education or experience from: * one or more years of claims handling experience * AINS, AIC, or CPCU designations preferred * bachelor's degree or equivalent experience required Benefits in addition to compensation include: * company car * company stock options, including Restricted Share Units and Incentive based stock options * paid time off (PTO) * 401K with 6% company match Enhance your talents Providing outstanding service and developing strong relationships with our independent agents are hallmarks of our company. Whether you have experience from another carrier or you're new to the insurance industry, we promote a lifelong learning approach. Cincinnati provides you with the tools and training to be successful and to become a trusted, respected insurance professional - all while enjoying a meaningful career. Enjoy benefits and amenities Your commitment to providing strong service, sharing best practices and creating solutions that impact lives is appreciated. To increase the well-being and satisfaction of our associates, we offer a variety of benefits and amenities. Embrace a diverse team As a relationship-based organization, we welcome and value a diverse workforce. We grant equal employment opportunity to all qualified persons without regard to race; creed; color; sex, including sexual orientation, gender identity and transgender status; religion; national origin; age; disability; military service; veteran status; pregnancy; AIDS/HIV or genetic information; or any other basis prohibited by law. All job applicants have rights under Federal Employment Laws. Please review this information to learn more about those rights.

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

Apply Materials Examiner & Identifier Department of Defense Defense Logistics Agency Apply Print Share * * * * Save * This job is open to * Requirements * How you will be evaluated * Required documents * How to apply See below for important information regarding this job. Summary See below for important information regarding this job. Overview Help Accepting applications Open & closing dates 01/09/2026 to 01/19/2026 Salary $31.56 to - $36.82 per hour Pay scale & grade WG 7 Location 1 vacancy in the following location: Bremerton, WA Remote job No Telework eligible No Travel Required Occasional travel - You may be expected to travel for this position. Relocation expenses reimbursed No Appointment type Permanent - Multiple Appointment Types Work schedule Full-time Service Competitive Promotion potential 7 Job family (Series) * 6912 Materials Examining And Identifying Supervisory status No Security clearance Other Drug test Yes Financial disclosure No Bargaining unit status Yes Announcement number DLADist-26-12863269-MP Control number 854049100 This job is open to Help Federal employees - Competitive service Current federal employees whose agencies follow the U.S. Office of Personnel Management's hiring rules and pay scales. Career transition (CTAP, ICTAP, RPL) Federal employees whose job, agency or department was eliminated and are eligible for priority over other applicants. Veterans Veterans of the U.S. Armed Forces or a spouse, widow, widower or parent of a veteran, who may be eligible for derived preference Military spouses Military spouses of active duty service members or whose spouse is 100 percent disabled or died on active duty. Individuals with disabilities Individuals who are eligible under Schedule A. Clarification from the agency Federal employees are current/former permanent competitive service employees in the commuting area may apply. Veterans eligibilities are 30% or more Disabled Vet and Veterans Employment Opportunities Act (VEOA). Military Spouse Preference (MSP), Retained Grade Preference (RGP), and Military Reserve and National Guard Technician eligibles in the commuting area may apply. Videos Duties Help * Serves as a Materials Examiner and Identifier handling techniques and procedures required for the processing of hazardous and toxic materials, and other sensitive, critical, and controlled type commodities. * Examines and identifies the most complex and difficult items received by the Site. * Serves as an authoritative source and possesses seasoned knowledge and experience with ability to detect defects in conspicuous places. * Resolves problems with damaged shipments and determines whether to accept/ reject, suspend item, or forward to property disposal. * Incumbent is delegated the authority to make final determinations on the acceptance of materiel. * Incumbent is delegated independent responsibility, or assigning condition classification, shelf-life codes, and the determination whether to repair or to dispose of the material. * Operates materials handling equipment to move, load and unload, stack or unstack palletized materials, supplies and equipment. Requirements Help Conditions of employment * Must be a U.S. citizen * Tour of Duty: Set Schedule * Security Requirements: Non-Critical Sensitive with Secret Access * Appointment is subject to the completion of a favorable suitability or fitness determination, where reciprocity cannot be applied; unfavorably adjudicated background checks will be grounds for removal. * Fair Labor Standards Act (FLSA): Non-Exempt * Selective Service Requirement: Males born after 12-31-59 must be registered or exempt from Selective Service. * Recruitment Incentives: Not Authorized * Bargaining Unit Status: Yes * Selectees are required to have a REAL ID or other acceptable identification documents to access certain federal facilities. See *************************** for more information. * Pre-Employment Physical: Required * This position and any future selections from this announcement may be used to fill various shifts located anywhere within DLA Distribution Puget Sound, WA. * Must be able to obtain and maintain licenses and/or certifications required by the installation, federal, state, and local laws. * Must be able to obtain and maintain required hazardous materials handling certifications. Qualifications Applicants will be rated in accordance with the Office of Personnel Management Qualification Standard for Trades and Labor Occupations. Although a specific length of time and experience is not required, you must meet any screen-out element listed, and show through experience and training that you possess the quality level of knowledge and skill necessary to perform the duties at the level for which you are applying. Emphasis is placed on how you gained the quality of experience, not necessarily the length of time, and the required ability or potential to perform the job. Applicants who do not meet the screen-out element (SOE) will be eliminated from further competition. Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional, philanthropic, religious, spiritual, community, student, social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience. Physical Effort: Work is performed on hard surface and in areas that require standing, stooping, bending, lifting and working in tiring and uncomfortable positions. Frequently lifts and carries items weighing 40 pounds, obtains assistance from others or uses materials handling equipment for items weighing over 40 pounds. Work requires dexterity for operating MHE. Employee may be subject to temperature variances. Is required to wear safety shoes and back belt when operating MHE like forklifts, tugs, general purpose warehouse vehicles, aisle mobile hybrid crane vehicles, etc. Working Conditions: Work is performed within a warehousing environment and outside in containment areas on a year round basis. Work is usually performed in areas that are hot, cold, or damp. Conditions may be uncomfortable when operating the aisle hybrid mobile crane near the ceiling. Maybe exposed to dusty, dirty or greasy conditions. Individuals maybe exposed to cuts, scrapes, bruises, abrasions, etc. While operating the aisle hybrid mobile crane, worker is required to wear special safety equipment, safety shoes, repelling harness, etc. Additional information For Important General Applicant Information and Definitions go to: ****************************************************************** Reemployed Annuitants: This position does not meet criteria for appointment of Reemployed Annuitants. The DoD criteria for hiring Reemployed Annuitants can be found at: ********************************************************************************** Information for Veterans is available at: ************************************** As of 23 December 2016, Military retirees seeking to enter federal service in the Department of Defense now require a waiver if they would be appointed within 180 days following their official date of retirement. Drug-Free Workplace Policy The Defense Logistics Agency (DLA) is committed to maintaining a safe, drug-free workplace. All DLA employees are required to refrain from illegal drug use on and off duty. DLA conducts pre-employment, reasonable suspicion, post-accident, and random drug testing. Applicants tentatively selected for employment in testing designated positions will undergo a urinalysis to screen for illegal drug use prior to appointment. Refusal to undergo testing or testing positive for illegal drugs will result in withdrawal of the tentative job offer and a six-month denial of employment with DLA from the date of the drug test. Employees in drug testing designated positions are subject to random drug testing. The DLA drug testing panel tests for the following substances: marijuana, cocaine, opiates, heroin, phencyclidine, amphetamines, methamphetamines, fentanyl, norfentanyl, methylenedioxymethamphetamine (MDMA), methylenedioxyamphetamine (MDA), and opioids. ADVISORY: Use of cannabidiol (CBD) products may result in a positive drug test for marijuana. DLA employees are subject to Federal law and under Federal law, Marijuana is a Schedule I drug and is illegal. Additional guidance on writing a federal resume can be found at: USAJOBS Help Center - How do I write a resume for a federal job? The resume builder can help you create a resume using these recommendations and uses the information in your USAJOBS profile to help you get started. Expand Hide additional information Candidates should be committed to improving the efficiency of the Federal government, passionate about the ideals of our American republic, and committed to upholding the rule of law and the United States Constitution. Benefits Help A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Opens in a new window Learn more about federal benefits. Review our benefits Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered. How you will be evaluated You will be evaluated for this job based on how well you meet the qualifications above. The assessments for this job will measure the following Job Elements/Competencies: * Ability to do the work of a Materials Examiner and Identifier without more than normal supervision (Screen-Out Element) * Knowledge of Technical Practices * Knowledge of Materials * Ability to Interpret Instructions, Specifications, etc. (other than blueprints) * Ability to Perform Work with Dexterity and Safety Once the application process is complete, a review of your resume and supporting documentation may be completed and compared against your responses to the assessment questionnaire to determine if you are qualified for this job. The rating you receive is based on your responses to the assessment questionnaire. The score is a measure of the degree to which your background matches the job elements/competencies required for this position. If your resume and/or supporting documentation is reviewed and a determination is made that you have inflated your qualifications and or experience, you may lose consideration for this position. Please follow all instructions carefully. Errors or omissions may affect your rating. Benefits Help A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Opens in a new window Learn more about federal benefits. Review our benefits Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered. Required documents Required Documents Help To apply for this position you must provide a complete Application Package. Each Application Package MUST include: * Your Resume: IMPORTANT UPDATE: Your resume must not exceed two (2) pages. If your resume exceeds the two-page limit, you will be removed from consideration for this announcement. The resume and required supporting documentation should provide the minimum qualifications and relevant experience for the announced position. Must include the work schedule, hours worked per week, dates of employment, and duties performed. If multiple resumes are submitted by an applicant, only the last resume submitted will be reviewed for qualifications and referred for selection consideration, if eligible. The resume must not be more than 5MB and should be saved and uploaded as a PDF to maintain formatting and number of pages. We also accept GIF, JPG, JPEG, PNG, RTF, TXT, PDF, ODT or Word (DOC or DOCX). We do not accept PDF portfolio files. Page margins should be 0.5 inches, and font styles must be legible. Consider using 14-point size font for titles and 10-point for the main text. We recommend using a font like Lato, if available. Other widely available options are Calibri, Helvetica, Arial, Verdana, Open San Source Sans Pro, Roboto or Noro Sans. * Applicable documents to support the eligibility(s) for which you are applying. Please review the following link for a listing of the additional documents you will need to provide: Supporting Documents. Interagency Career Transition Assistance Program (ICTAP): If you are an eligible ICTAP applicant you may apply for special selection over other candidates for this position. To be well-qualified and exercise selection priority for this vacancy, displaced Federal employees must be rated at a score of 85 or higher for this position. ICTAP eligibles must submit one of the following as proof of eligibility for the special selection priority: a separation notice; a "Notice of Personnel Action" (SF-50) documenting separation; an agency certification that you cannot be placed after injury compensation has been terminated; an OPM notification that your disability annuity has been terminated; OR a Military Department or National Guard Bureau notification that you are retired under 5 U.S.C. 8337(h) or 8456. Priority Placement Program (PPP) DoD Military Spouse Preference (MSP): In order to receive this preference, you must choose to apply using the "Priority Placement Program, DoD Military Spouse Preference (MSP)" eligibility. If you are claiming MSP and are determined to be among the Best Qualified for the position, you may be referred to the hiring manager as a priority applicant. To be eligible as a MSP, you must submit the following supporting documents with your application package: Spouse's Permanent Change of Station (PCS) orders; Marriage Certificate or License; PPP Self Certification Checklist; Veterans' Preference documentation (e.g., DD-214, VA Letter, Statement of Service, if applicable); Transcripts (if applicable). These documents must provide acceptable information to verify: Residency within the commuting area of your sponsor's permanent duty station (PDS); proof of marriage to the active duty sponsor; proof of military member's active duty status; and other documentation required by the vacancy announcement to which you are applying. NOTE: Previous federal employees must also submit the following additional documentation: SF-50s (e.g., LWOP, highest grade held, overseas appointments, etc.), SF-75 information, and documentation of performance rating of record (dated within the last 12 months). Selected PPP MSP applicants will need to certify they have not accepted nor declined another offer of permanent, Federal employment (to include NAF and the military exchange services) since relocating to the military sponsor's current duty station. Priority Placement Program (PPP) DoD Retained Grade Preference (RGP): In order to receive this preference, you must choose to apply using the "Priority Placement Program, DoD Retained Grade Preference (RGP)" eligibility. If you are claiming RGP and are determined to be Well Qualified (score of 85 or above) for the position, you will be referred to the hiring manager as a priority applicant. Information and required documentation for claiming RGP may be found at the General Applicant Information and Definitions link below. To be eligible as a RGP, you must submit the following supporting documents with your application package: a signed Retained Grade PPP Self-Certification Checklist (DD3145-1 (whs.mil)); a copy of your Notification of Personnel Action (SF-50) effecting the placement in retained grade status; or a copy of the notification letter you received regarding the RIF or classification downgrade. If you are relying on your education to meet qualification requirements: Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications. Therefore, provide only the attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education. Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating. How to Apply Help To apply for this position, you must complete the online application and submit the documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (EST) on the closing date to receive consideration. * To begin, click Apply Online to access an online application. Follow the prompts to select your USAJOBS resume and/or other supporting documents. You will need to be logged into your USAJOBS account or you may need to create a new account. * You will be taken to an online application. Complete the online application, verify the required documentation, and submit the application. NOTE: Resumes up to a total of two pages will be accepted. Your resume must not exceed two (2) pages. If your resume exceeds the two-page limit, you will be removed from consideration for this announcement. * You will receive an email notification when your application has been received for the announcement. * To verify the status of your application, log into your USAJOBS account, ************************ select the Application Status link and then select the More Information link for this position. The Application Status page will display the status of your application, the documentation received and processed, and your responses submitted to the online application. Your uploaded documents may take several hours to clear the virus scan process. To preview the questionnaire, please go to ********************************************************* Agency contact information Ashley Nieves Email ********************* Address DLA Distribution Puget Sound 467 West Street Bremerton, WA 98314 US Next steps Once you successfully complete the application process, you will receive a notification of receipt. Your application package will be reviewed to ensure you meet the basic eligibility and qualifications requirements, and you will receive a notification. A review may be completed of your online questionnaire and the documentation you submitted to support your responses. Applicants that are found among the most highly qualified may be referred to the hiring official for consideration, and you will receive a notification of referral. The selecting official may choose to conduct interviews, and as part of the selection process, applicants may be required to complete additional supplemental documents. Once the selection is made, you will receive a notification of the decision. If interviews are conducted, DLA uses a technique called Behavior Based Interviewing (BBI). Be sure to check your USA Jobs account for your notification updates. Fair and transparent The Federal hiring process is set up to be fair and transparent. Please read the following guidance. Criminal history inquiries Equal Employment Opportunity (EEO) Policy Financial suitability New employee probationary period Privacy Act Reasonable accommodation policy Selective Service Signature and false statements Social security number request Required Documents Help To apply for this position you must provide a complete Application Package. Each Application Package MUST include: * Your Resume: IMPORTANT UPDATE: Your resume must not exceed two (2) pages. If your resume exceeds the two-page limit, you will be removed from consideration for this announcement. The resume and required supporting documentation should provide the minimum qualifications and relevant experience for the announced position. Must include the work schedule, hours worked per week, dates of employment, and duties performed. If multiple resumes are submitted by an applicant, only the last resume submitted will be reviewed for qualifications and referred for selection consideration, if eligible. The resume must not be more than 5MB and should be saved and uploaded as a PDF to maintain formatting and number of pages. We also accept GIF, JPG, JPEG, PNG, RTF, TXT, PDF, ODT or Word (DOC or DOCX). We do not accept PDF portfolio files. Page margins should be 0.5 inches, and font styles must be legible. Consider using 14-point size font for titles and 10-point for the main text. We recommend using a font like Lato, if available. Other widely available options are Calibri, Helvetica, Arial, Verdana, Open San Source Sans Pro, Roboto or Noro Sans. * Applicable documents to support the eligibility(s) for which you are applying. Please review the following link for a listing of the additional documents you will need to provide: Supporting Documents. Interagency Career Transition Assistance Program (ICTAP): If you are an eligible ICTAP applicant you may apply for special selection over other candidates for this position. To be well-qualified and exercise selection priority for this vacancy, displaced Federal employees must be rated at a score of 85 or higher for this position. ICTAP eligibles must submit one of the following as proof of eligibility for the special selection priority: a separation notice; a "Notice of Personnel Action" (SF-50) documenting separation; an agency certification that you cannot be placed after injury compensation has been terminated; an OPM notification that your disability annuity has been terminated; OR a Military Department or National Guard Bureau notification that you are retired under 5 U.S.C. 8337(h) or 8456. Priority Placement Program (PPP) DoD Military Spouse Preference (MSP): In order to receive this preference, you must choose to apply using the "Priority Placement Program, DoD Military Spouse Preference (MSP)" eligibility. If you are claiming MSP and are determined to be among the Best Qualified for the position, you may be referred to the hiring manager as a priority applicant. To be eligible as a MSP, you must submit the following supporting documents with your application package: Spouse's Permanent Change of Station (PCS) orders; Marriage Certificate or License; PPP Self Certification Checklist; Veterans' Preference documentation (e.g., DD-214, VA Letter, Statement of Service, if applicable); Transcripts (if applicable). These documents must provide acceptable information to verify: Residency within the commuting area of your sponsor's permanent duty station (PDS); proof of marriage to the active duty sponsor; proof of military member's active duty status; and other documentation required by the vacancy announcement to which you are applying. NOTE: Previous federal employees must also submit the following additional documentation: SF-50s (e.g., LWOP, highest grade held, overseas appointments, etc.), SF-75 information, and documentation of performance rating of record (dated within the last 12 months). Selected PPP MSP applicants will need to certify they have not accepted nor declined another offer of permanent, Federal employment (to include NAF and the military exchange services) since relocating to the military sponsor's current duty station. Priority Placement Program (PPP) DoD Retained Grade Preference (RGP): In order to receive this preference, you must choose to apply using the "Priority Placement Program, DoD Retained Grade Preference (RGP)" eligibility. If you are claiming RGP and are determined to be Well Qualified (score of 85 or above) for the position, you will be referred to the hiring manager as a priority applicant. Information and required documentation for claiming RGP may be found at the General Applicant Information and Definitions link below. To be eligible as a RGP, you must submit the following supporting documents with your application package: a signed Retained Grade PPP Self-Certification Checklist (DD3145-1 (whs.mil)); a copy of your Notification of Personnel Action (SF-50) effecting the placement in retained grade status; or a copy of the notification letter you received regarding the RIF or classification downgrade. If you are relying on your education to meet qualification requirements: Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications. Therefore, provide only the attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education. Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.

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 Liability Claims Examiner - General Liability Are you looking for an opportunity to join a global industry leader where you can bring your big ideas to help solve problems for some of the world's best brands? * Apply your knowledge and experience to adjudicate complex customer claims in the context of an energetic culture. * Deliver innovative customer-facing solutions to clients who represent virtually every industry and comprise some of the world's most respected organizations. * Be a part of a rapidly growing, industry-leading global company known for its excellence and customer service. * Leverage Sedgwick's broad, global network of experts to both learn from and to share your insights. * Take advantage of a variety of professional development opportunities that help you perform your best work and grow your career. * Enjoy flexibility and autonomy in your daily work, your location, and your career path. * Access diverse and comprehensive benefits to take care of your mental, physical, financial and professional needs. ARE YOU AN IDEAL CANDIDATE? We are looking for driven individuals that embody our caring counts model and core values that include empathy, accountability, collaboration, growth, and inclusion. PRIMARY PURPOSE: To analyze complex or technically difficult general liability and auto liability claims to determine benefits due; to work with high exposure claims involving litigation and rehabilitation; to ensure ongoing adjudication of claims within service expectations, industry best practices and specific client service requirements; and to identify subrogation of claims and negotiate settlements. ESSENTIAL FUNCTIONS and RESPONSIBILITIES * Analyzes and processes complex or technically difficult general liability and auto liability claims by investigating and gathering information to determine the exposure on the claim; manages claims through well-developed action plans to an appropriate and timely resolution. * Assesses liability and resolves claims within evaluation. * Negotiates settlement of claims within designated authority. * Calculates and assigns timely and appropriate reserves to claims; manages reserve adequacy throughout the life of the claim. * Calculates and pays benefits due; approves and makes timely claim payments and adjustments; and settles clams within designated authority level. * Prepares necessary state fillings within statutory limits. * Manages the litigation process; ensures timely and cost effective claims resolution. * Coordinates vendor referrals for additional investigation and/or litigation management. * Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims for our clients. * Manages claim recoveries, including but not limited to: subrogation, Second Injury Fund excess recoveries and Social Security and Medicare offsets. * Reports claims to the excess carrier; responds to requests of directions in a professional and timely manner. * Communicates claim activity and processing with the claimant and the client; maintains professional client relationships. * Ensures claim files are properly documented and claims coding is correct. * Refers cases as appropriate to supervisor and management. QUALIFICATION Education & Licensing Bachelor's degree from an accredited college or university preferred. Professional certification as applicable to line of business preferred. Experience Five (5) years of General Liability claims management experience or equivalent combination of education and experience required. Skills & Knowledge * Subject matter expert of appropriate insurance principles and laws for line-of-business handled, recoveries offsets and deductions, claim and disability duration, cost containment principles including medical management practices and Social Security and Medicare application procedures as applicable to line-of-business. * Excellent oral and written communication, including presentation skills * PC literate, including Microsoft Office products * Analytical and interpretive skills * Strong organizational skills * Good interpersonal skills * Excellent negotiation skills * Ability to work in a team environment * Ability to meet or exceed Service Expectations TAKING CARE OF YOU * Flexible work schedule. * Referral incentive program. * Career development and promotional growth opportunities. * A diverse and comprehensive benefits offering including medical, dental vision, 401K on day one. 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 $75,000 - $95,000. 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 #Hybrid #LI-Hybrid #LI-Remote #LI-AM1 Qualified applicants with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers, the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, the San Diego Fair Chance Ordinance, the San Francisco Fair Chance Ordinance, the California Fair Chance Act, and all other applicable laws. 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.

Adjudicates claims submitted by outside purchased services for PMC's enrolled capitated population and communicates those actions. Adjusts complex claims for advanced processing needs. Responds to Customer Service Requests and resolves problem claim situations. Providence caregivers are not simply valued - they're invaluable. Join our team at Pacmed Clinics DBA Pacific Medical Centers and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them. Required Qualifications: + H.S. Diploma or GED or equivalent experience in Health Care Business Administration. + 2 years in Managed Care operations. + 1 year of Claims processing experience, in a TPA, MSO, HMO, PHO or large group practice setting. + Experience with areas of specialty claim processing (COB, Adjustments, Point of Service, Home Health and Encounters). + Information systems supporting the administration of managed care products. Preferred Qualifications: + IDX healthcare software application. + CHAMPUS, Medicare and/or Medicaid benefits/programs. Why Join Providence? Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally and achieving financial security. We take care of you, so you can focus on delivering our mission to advocate, educate and provide extraordinary care. About Providence At Providence, our strength lies in Our Promise of "Know me, care for me, ease my way." Working at our family of organizations means that regardless of your role, we'll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable. Posted are the minimum and the maximum wage rates on the wage range for this position. The successful candidate's placement on the wage range for this position will be determined based upon relevant job experience and other applicable factors. These amounts are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities. Providence offers a comprehensive benefits package including a retirement 401(k) Savings Plan with employer matching, health care benefits (medical, dental, vision), life insurance, disability insurance, time off benefits (paid parental leave, vacations, holidays, health issues), voluntary benefits, well-being resources and much more. Learn more at providence.jobs/benefits. Applicants in the Unincorporated County of Los Angeles: Qualified applications with arrest or conviction records will be considered for employment in accordance with the Unincorporated Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act. About the Team Pacific Medical Centers (PacMed) is a private, not-for-profit, primary and integrated multi-specialty health care network with outpatient clinics and primary and specialty care providers in King, Snohomish and Pierce counties. We combine decades of patient-centered care with cutting-edge technology, first-class facilities and board-certified providers. Our strong team environment and respect for our people-at all levels and from all backgrounds-allow us to provide authentic care that achieves the highest-quality patient outcomes, backed by the strong network of resources and support through our affiliation with the Providence family, including local partners like Swedish Health Services. Providence is proud to be an Equal Opportunity Employer. We are committed to the principle that every workforce member has the right to work in surroundings that are free from all forms of unlawful discrimination and harassment on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law. We believe diversity makes us stronger, so we are dedicated to shaping an inclusive workforce, learning from each other, and creating equal opportunities for advancement. For any concerns with this posting relating to the posting requirements in RCW 49.58.110(1), please click here where you can access an email link to submit your concern. Requsition ID: 404135 Company: Pacific Medical Jobs Job Category: Claims Job Function: Revenue Cycle Job Schedule: Full time Job Shift: Day Career Track: Admin Support Department: 3060 WA USFHP Address: WA Seattle 1200 12th Ave S Work Location: PACMED Admin Bh-Seattle Workplace Type: On-site Pay Range: $21.01 - $32.57 The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.

Adjudicates claims submitted by outside purchased services for PMC's enrolled capitated population and communicates those actions. Adjusts complex claims for advanced processing needs. Responds to Customer Service Requests and resolves problem claim situations. Providence caregivers are not simply valued - they're invaluable. Join our team at Pacmed Clinics DBA Pacific Medical Centers and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them. Required Qualifications: H.S. Diploma or GED or equivalent experience in Health Care Business Administration. 2 years in Managed Care operations. 1 year of Claims processing experience, in a TPA, MSO, HMO, PHO or large group practice setting. Experience with areas of specialty claim processing (COB, Adjustments, Point of Service, Home Health and Encounters). Information systems supporting the administration of managed care products. Preferred Qualifications: IDX healthcare software application. CHAMPUS, Medicare and/or Medicaid benefits/programs. Why Join Providence? Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally and achieving financial security. We take care of you, so you can focus on delivering our mission to advocate, educate and provide extraordinary care.

HealthCare Support Staffing, Inc. (HSS), is a proven industry-leading national healthcare recruiting and staffing firm. HSS has a proven history of placing talented healthcare professionals in clinical and non-clinical positions with some of the largest and most prestigious healthcare facilities including: Fortune 100 Health Plans, Mail Order Pharmacies, Medical Billing Centers, Hospitals, Laboratories, Surgery Centers, Private Practices, and many other healthcare facilities throughout the United States. HealthCare Support Staffing maintains strong relationships with top providers in healthcare and can assure healthcare professionals they will receive fast access to great career opportunities that best fit their expertise. Connect with one of our Professional Recruiting Consultants today to see how a conversation can turn into a long-lasting and rewarding career! Job Description Are you an experienced Provider Service Rep looking for a new opportunity with a prestigious healthcare company? Do you want the chance to advance your career by joining a rapidly growing company? If you answered “yes" to any of these questions - this is the position for you! Daily Responsibilities: • Resolve customer inquiries via telephone and written correspondence in a timely and appropriate manner. • Provide assistance to provider regarding website registration, navigation and customer related inquires • Educate provider on health plan initiatives during interactions with providers via telephone Hours for this Position: Monday-Friday 8am-5pm Start Date: 01/11/2016 Advantages of this Opportunity: • Competitive salary based on experience, negotiable based on relevant experience • Benefits offered, Medical, Dental, and Vision • Fun and positive work environment Qualifications • High school diploma or GED Required. • Healthcare and/or call center experience • Knowledge of Medicare/Medicaid • Looking for experience with claims/billing Additional Information Interested in being considered? If you are interested in applying to this position, please contact Sheena Lagaylay @ 407-965-2843 and click the Green I'm Interested Button to email your resume.

Provides analyst support for claims research activities including reviewing and researching claims to ensure regulatory requirements are appropriately applied, identifying root-cause of processing errors through research and analysis, coordinating and engaging with appropriate departments, developing and tracking remediation plans, and monitoring claims reprocessing through resolution. **Essential Job Duties** - Serves as claims subject matter expert - using analytical skills to conduct research and analysis to address issues, requests, and support high-priority claims inquiries and projects. - Interprets and presents in-depth analysis of claims research findings and results to leadership and respective operations teams. - Manages and leads major claims projects of considerable complexity and volume that may be initiated internally, or through provider inquiries/complaints, or legal requests. - Assists with reducing rework by identifying and remediating claims processing issues. - Locates and interprets claims-related regulatory and contractual requirements. - Tailors existing reports and/or available data to meet the needs of claims projects. - Evaluates claims using standard principles and applicable state-specific regulations to identify claims processing errors. - Applies claims processing and technical knowledge to appropriately define a path for short/long-term systematic or operational fixes. - Seeks to improve overall claims performance, and ensure claims are processed accurately and timely. - Identifies claims requiring reprocessing or readjudication in a timely manner to ensure compliance. - Works collaboratively with internal/external stakeholders to define claims requirements. - Recommends updates to claims standard operating procedures (SOPs) and job aids to increase the quality and efficiency of claims processing. - Fields claims questions from the operations team. - Interprets, communicates, and presents, clear in-depth analysis of claims research results, root-cause analysis, remediation plans and fixes, overall progress, and status of impacted claims. - Appropriately conveys claims-related information and tailors communication based on targeted audiences. - Provides sufficient claims information to internal operations teams that communicate externally with providers and/or members. - Collaborates with other functional teams on claims-related projects, and completes tasks within designated/accelerated timelines to minimize provider/member impacts and maintain compliance. - Supports claims department initiatives to improve overall claims function efficiency. **Required Qualifications** - At least 3 years of medical claims processing experience, or equivalent combination of relevant education and experience. - Medical claims processing experience across multiple states, markets, and claim types. - Knowledge of claims processing related to inpatient/outpatient facilities contracted with Medicare, Medicaid, and Marketplace government-sponsored programs. - Data research and analysis skills. - Organizational skills and attention to detail. - Time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines. - Ability to work cross-collaboratively in a highly matrixed organization. - Customer service skills. - Effective verbal and written communication skills. - Microsoft Office suite (including Excel), and applicable software programs proficiency. **Preferred Qualifications** - Health care claims analysis experience. - Project management experience. - QNXT, Salesforce and basic SQL To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $21.65 - $46.42 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

This job reviews, evaluates, and processes various Stop Loss (Excess Risk and Reinsurance) claims in accordance with established turnaround and quality standards. Responsible for building positive client relationships, providing education, and analyzing client claim losses as well as current issues regarding client activities; disseminates necessary information to the management. Follows up on pended claims in accordance with department standards. HNAS (Health Now Administrative Services) offers flexible, cost-effective solutions for employee health benefits. HNAS is part of Highmark Health, a national blended health organization with a mission to create remarkable health experiences. Our culture is built on your growth and development, collaborating across our organization, and making a big impact for those we serve. **ESSENTIAL RESPONSIBILITIES** + Processes daily incoming Stop Loss claims including initial entry claims or subsequent claims as needed; provides counseling to clients and assists with client service programs. + Evaluates various claims submitted by Third Party Administrators (TPAs) and Pharmacy Benefit Managers (PBMs) on behalf of self-funded clients for compliance with the following: underlying policy provisions, federal and state regulatory guidelines, and industry standards. + Monitors, reviews and analyzes various complex potential claims with emphasis on controlling losses through effective managed care. This includes following a departmental claim checklist to ensure eligibility is met, the payment reimbursement request is accurate by auditing the claim for duplicate line-item charges and determining if all information is available to finalize the payment request. Refers the claim to the cost containment and RxOps departments for review of high dollar charges if applicable. + Determines whether to pend or adjudicate claims following organizational policies and procedures; finalizes and adjudicates claims up to pre-determined dollar threshold. Completes pended claim letters for incomplete, invalid, or missing claim information to TPAs, brokers, or customers utilizing the appropriate application and/or template. + Identifies potential discrepancies in claim submissions and involves the Special Investigation Unit as necessary. Identifies issues which can be used to educate/train internal staff, streamline, and improve processes and update documentation. + Assists leadership with performing client performance evaluations to assess the accuracy of client reports submitted to the organization, efficiency of claim operations, and adequacy of systems and procedures. + Approves claim payments on behalf of multiple clients and provides client counseling and support services. Assists in the client service programs including revising and establishing procedures, protocols and ensuring client satisfaction with the organization. + Maintains accurate claim records. + Other duties as assigned or requested. **EDUCATION** **Required** + High School Diploma/GED **Substitutions** + None **Preferred** + Bachelor's degree **EXPERIENCE** **Required** + 5 years of relevant, progressive experience in health insurance claims + 3 years of prior experience processing 1st dollar health insurance claims + 3 years of experience with medical terminology **Preferred:** + 3 years of experience in a Stop Loss Claims Analyst role. **SKILLS** + Ability to communicate concise accurate information effectively. + Organizational skills + Ability to manage time effectively. + Ability to work independently. + Problem Solving and analytical skills. **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:** $22.71 **Pay Range Maximum:** $35.18 _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. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at ***************************** California Consumer Privacy Act Employees, Contractors, and Applicants Notice Req ID: J273755

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 Liability Claims Examiner - General Liability Are you looking for an opportunity to join a global industry leader where you can bring your big ideas to help solve problems for some of the world's best brands? + Apply your knowledge and experience to adjudicate complex customer claims in the context of an energetic culture. + Deliver innovative customer-facing solutions to clients who represent virtually every industry and comprise some of the world's most respected organizations. + Be a part of a rapidly growing, industry-leading global company known for its excellence and customer service. + Leverage Sedgwick's broad, global network of experts to both learn from and to share your insights. + Take advantage of a variety of professional development opportunities that help you perform your best work and grow your career. + Enjoy flexibility and autonomy in your daily work, your location, and your career path. + Access diverse and comprehensive benefits to take care of your mental, physical, financial and professional needs. **ARE YOU AN IDEAL CANDIDATE?** We are looking for driven individuals that embody our caring counts model and core values that include empathy, accountability, collaboration, growth, and inclusion. **PRIMARY PURPOSE** : To analyze complex or technically difficult general liability and auto liability claims to determine benefits due; to work with high exposure claims involving litigation and rehabilitation; to ensure ongoing adjudication of claims within service expectations, industry best practices and specific client service requirements; and to identify subrogation of claims and negotiate settlements. **ESSENTIAL FUNCTIONS and RESPONSIBILITIES** + Analyzes and processes complex or technically difficult general liability and auto liability claims by investigating and gathering information to determine the exposure on the claim; manages claims through well-developed action plans to an appropriate and timely resolution. + Assesses liability and resolves claims within evaluation. + Negotiates settlement of claims within designated authority. + Calculates and assigns timely and appropriate reserves to claims; manages reserve adequacy throughout the life of the claim. + Calculates and pays benefits due; approves and makes timely claim payments and adjustments; and settles clams within designated authority level. + Prepares necessary state fillings within statutory limits. + Manages the litigation process; ensures timely and cost effective claims resolution. + Coordinates vendor referrals for additional investigation and/or litigation management. + Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims for our clients. + Manages claim recoveries, including but not limited to: subrogation, Second Injury Fund excess recoveries and Social Security and Medicare offsets. + Reports claims to the excess carrier; responds to requests of directions in a professional and timely manner. + Communicates claim activity and processing with the claimant and the client; maintains professional client relationships. + Ensures claim files are properly documented and claims coding is correct. + Refers cases as appropriate to supervisor and management. **QUALIFICATION** **Education & Licensing** Bachelor's degree from an accredited college or university preferred. Professional certification as applicable to line of business preferred. **Experience** Five (5) years of General Liability claims management experience or equivalent combination of education and experience required. **Skills & Knowledge** + Subject matter expert of appropriate insurance principles and laws for line-of-business handled, recoveries offsets and deductions, claim and disability duration, cost containment principles including medical management practices and Social Security and Medicare application procedures as applicable to line-of-business. + Excellent oral and written communication, including presentation skills + PC literate, including Microsoft Office products + Analytical and interpretive skills + Strong organizational skills + Good interpersonal skills + Excellent negotiation skills + Ability to work in a team environment + Ability to meet or exceed Service Expectations **TAKING CARE OF YOU** + Flexible work schedule. + Referral incentive program. + Career development and promotional growth opportunities. + A diverse and comprehensive benefits offering including medical, dental vision, 401K on day one. _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 $75,000 - $95,000. 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 #Hybrid #LI-Hybrid #LI-Remote #LI-AM1 Qualified applicants with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers, the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, the San Diego Fair Chance Ordinance, the San Francisco Fair Chance Ordinance, the California Fair Chance Act, and all other applicable laws. 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**

Adjudicates claims submitted by outside purchased services for PMC's enrolled capitated population and communicates those actions. Adjusts complex claims for advanced processing needs. Responds to Customer Service Requests and resolves problem claim situations. Providence caregivers are not simply valued - they're invaluable. Join our team at Pacmed Clinics DBA Pacific Medical Centers and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them. Required Qualifications: + H.S. Diploma or GED or equivalent experience in Health Care Business Administration. + 2 years in Managed Care operations. + 1 year of Claims processing experience, in a TPA, MSO, HMO, PHO or large group practice setting. + Experience with areas of specialty claim processing (COB, Adjustments, Point of Service, Home Health and Encounters). + Information systems supporting the administration of managed care products. Preferred Qualifications: + IDX healthcare software application. + CHAMPUS, Medicare and/or Medicaid benefits/programs. Why Join Providence? Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally and achieving financial security. We take care of you, so you can focus on delivering our mission to advocate, educate and provide extraordinary care. About Providence At Providence, our strength lies in Our Promise of "Know me, care for me, ease my way." Working at our family of organizations means that regardless of your role, we'll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable. Posted are the minimum and the maximum wage rates on the wage range for this position. The successful candidate's placement on the wage range for this position will be determined based upon relevant job experience and other applicable factors. These amounts are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities. Providence offers a comprehensive benefits package including a retirement 401(k) Savings Plan with employer matching, health care benefits (medical, dental, vision), life insurance, disability insurance, time off benefits (paid parental leave, vacations, holidays, health issues), voluntary benefits, well-being resources and much more. Learn more at providence.jobs/benefits. Applicants in the Unincorporated County of Los Angeles: Qualified applications with arrest or conviction records will be considered for employment in accordance with the Unincorporated Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act. About the Team Pacific Medical Centers (PacMed) is a private, not-for-profit, primary and integrated multi-specialty health care network with outpatient clinics and primary and specialty care providers in King, Snohomish and Pierce counties. We combine decades of patient-centered care with cutting-edge technology, first-class facilities and board-certified providers. Our strong team environment and respect for our people-at all levels and from all backgrounds-allow us to provide authentic care that achieves the highest-quality patient outcomes, backed by the strong network of resources and support through our affiliation with the Providence family, including local partners like Swedish Health Services. Providence is proud to be an Equal Opportunity Employer. We are committed to the principle that every workforce member has the right to work in surroundings that are free from all forms of unlawful discrimination and harassment on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law. We believe diversity makes us stronger, so we are dedicated to shaping an inclusive workforce, learning from each other, and creating equal opportunities for advancement. For any concerns with this posting relating to the posting requirements in RCW 49.58.110(1), please click here where you can access an email link to submit your concern. Requsition ID: 404135 Company: Pacific Medical Jobs Job Category: Claims Job Function: Revenue Cycle Job Schedule: Full time Job Shift: Day Career Track: Admin Support Department: 3060 WA USFHP Address: WA Seattle 1200 12th Ave S Work Location: PACMED Admin Bh-Seattle Workplace Type: On-site Pay Range: $21.01 - $32.57 The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.

HealthCare Support Staffing, Inc. (HSS), is a proven industry-leading national healthcare recruiting and staffing firm. HSS has a proven history of placing talented healthcare professionals in clinical and non-clinical positions with some of the largest and most prestigious healthcare facilities including: Fortune 100 Health Plans, Mail Order Pharmacies, Medical Billing Centers, Hospitals, Laboratories, Surgery Centers, Private Practices, and many other healthcare facilities throughout the United States. HealthCare Support Staffing maintains strong relationships with top providers in healthcare and can assure healthcare professionals they will receive fast access to great career opportunities that best fit their expertise. Connect with one of our Professional Recruiting Consultants today to see how a conversation can turn into a long-lasting and rewarding career! Job Description Job Title Member Service/Provider Service Healthcare Rep City, State: Tacoma, Washington Position Summary: Receive and respond to member/provider inquires. Hours for this Position: M-F 8:00-5:00 pm Advantages of this Opportunity: •Competitive salary 14-19hr •Fun and positive work environment •Long term position (Benefits Offered) •Advancement Opportunities More Insight of Daily Responsibilities: •Receive and respond to all telephone or written correspondence inquiries from members within established timeframes and policies. •Assist members with plan benefits via telephone, in writing, in person or make referral to outreach representative as appropriate. •Document in the computer system all members' issues and resolution. •Utilize current reference materials to assist and resolve any member inquiries. •May coordinate member transportation. Qualifications What We Look For: • MUST have HS Diploma or GED (Verifiable! pass on candidates w/ degrees from other countries we can't verify) - Please list on resume • MUST have Healthcare experience • Must have Claims Experience any type (Commercial, Medicare, and Medicaid) • Call Center experience strongly preferred but no required. With that being said we need to make sure 100% that they are comfortable working in this type of environment. • Will consider candidates w/ Healthcare expr & have provided ‘customer service' to people, but don't have to be in a call center setting • For EXP: Front Desk in a busy doctor's office where they are answering phones, greeting patients, scheduling appts, etc. Additional Information Are you an experienced Member Service/Provider Service/Enrollement Rep looking for a new opportunity with a prestigious healthcare company? Do you have experience with Medicare/Medicaid Claims? Do you want the chance to advance your career by joining a rapidly growing company? If you answered “yes" to any of these questions - this is the position for you! If interested in learning more please contact Ryan Chojnacki by replying to this job post and including your resume

Provides analyst support for claims research activities including reviewing and researching claims to ensure regulatory requirements are appropriately applied, identifying root-cause of processing errors through research and analysis, coordinating and engaging with appropriate departments, developing and tracking remediation plans, and monitoring claims reprocessing through resolution. Essential Job Duties * Serves as claims subject matter expert - using analytical skills to conduct research and analysis to address issues, requests, and support high-priority claims inquiries and projects. * Interprets and presents in-depth analysis of claims research findings and results to leadership and respective operations teams. * Manages and leads major claims projects of considerable complexity and volume that may be initiated internally, or through provider inquiries/complaints, or legal requests. * Assists with reducing rework by identifying and remediating claims processing issues. * Locates and interprets claims-related regulatory and contractual requirements. * Tailors existing reports and/or available data to meet the needs of claims projects. * Evaluates claims using standard principles and applicable state-specific regulations to identify claims processing errors. * Applies claims processing and technical knowledge to appropriately define a path for short/long-term systematic or operational fixes. * Seeks to improve overall claims performance, and ensure claims are processed accurately and timely. * Identifies claims requiring reprocessing or readjudication in a timely manner to ensure compliance. * Works collaboratively with internal/external stakeholders to define claims requirements. * Recommends updates to claims standard operating procedures (SOPs) and job aids to increase the quality and efficiency of claims processing. * Fields claims questions from the operations team. * Interprets, communicates, and presents, clear in-depth analysis of claims research results, root-cause analysis, remediation plans and fixes, overall progress, and status of impacted claims. * Appropriately conveys claims-related information and tailors communication based on targeted audiences. * Provides sufficient claims information to internal operations teams that communicate externally with providers and/or members. * Collaborates with other functional teams on claims-related projects, and completes tasks within designated/accelerated timelines to minimize provider/member impacts and maintain compliance. * Supports claims department initiatives to improve overall claims function efficiency. Required Qualifications * At least 3 years of medical claims processing experience, or equivalent combination of relevant education and experience. * Medical claims processing experience across multiple states, markets, and claim types. * Knowledge of claims processing related to inpatient/outpatient facilities contracted with Medicare, Medicaid, and Marketplace government-sponsored programs. * Data research and analysis skills. * Organizational skills and attention to detail. * Time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines. * Ability to work cross-collaboratively in a highly matrixed organization. * Customer service skills. * Effective verbal and written communication skills. * Microsoft Office suite (including Excel), and applicable software programs proficiency. Preferred Qualifications * Health care claims analysis experience. * Project management experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $22.81 - $46.42 / HOURLY * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

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 PL CLAIM SPECIALIST **PRIMARY PURPOSE** **:** To analyze complex or technically difficult medical malpractice claims; to provide resolution of highly complex nature and/or severe injury claims; to coordinate case management within Company standards, industry best practices and specific client service requirements; and to manage the total claim costs while providing high levels of customer service. **ESSENTIAL FUNCTIONS and RESPONSIBILITIES** + Analyzes and processes complex or technically difficult medical malpractice claims by investigating and gathering information to determine the exposure on the claim; manages claims through well-developed action plans to an appropriate and timely resolution. + Conducts or assigns full investigation and provides report of investigation pertaining to new events, claims and legal actions. + Negotiates claim settlement up to designated authority level. + Calculates and assigns timely and appropriate reserves to claims; monitors reserve adequacy throughout claim life. + Recommends settlement strategies; brings structured settlement proposals as necessary to maximize settlement. + Coordinates legal defense by assigning attorney, coordinating support for investigation, and reviewing attorney invoices; monitors counsel for compliance with client guidelines. + Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall claim cost for our clients. + Identifies and investigates for possible fraud, subrogation, contribution, recovery, and case management opportunities to reduce total claim cost. + Represents Company in depositions, mediations, and trial monitoring as needed. + Communicates claim activity and processing with the client; maintains professional client relationships. + Ensures claim files are properly documented and claims coding is correct. + Refers cases as appropriate to supervisor and management. + Delegates work and mentors assigned staff. **ADDITIONAL FUNCTIONS and RESPONSIBILITIES** + Performs other duties as assigned. + Supports the organization's quality program(s). **QUALIFICATIONS** **Education & Licensing** Bachelor's degree from an accredited college or university preferred. Licenses as required. Professional certification as applicable to line of business preferred. **Experience** Six (6) years of claims management experience or equivalent combination of education and experience required. **Skills & Knowledge** + In-depth knowledge of appropriate medical malpractice insurance principles and laws for line-of-business handled, recoveries offsets and deductions, claim and disability duration, cost containment principles including medical management practices and Social Security application procedures as applicable to line-of-business + Excellent oral and written communication, including presentation skills + PC literate, including Microsoft Office products + Analytical and interpretive skills + Strong organizational skills + Excellent negotiation skills + Good interpersonal skills + Ability to work in a team environment + Ability to meet or exceed Performance Competencies **WORK ENVIRONMENT** When applicable and appropriate, consideration will be given to reasonable accommodations. **Mental** **:** Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines **Physical** **:** Computer keyboarding, travel as required **Auditory/Visual** **:** Hearing, vision and talking _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 $117,000 - $125,000. 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._ The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time. 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**

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