Claim processor jobs in Vermont

Datavant is a data platform company and the world's leader in health data exchange. Our vision is that every healthcare decision is powered by the right data, at the right time, in the right format. Our platform is powered by the largest, most diverse health data network in the U.S., enabling data to be secure, accessible and usable to inform better health decisions. Datavant is trusted by the world's leading life sciences companies, government agencies, and those who deliver and pay for care. By joining Datavant today, you're stepping onto a high-performing, values-driven team. Together, we're rising to the challenge of tackling some of healthcare's most complex problems with technology-forward solutions. Datavanters bring a diversity of professional, educational and life experiences to realize our bold vision for healthcare. This is a Remote role - Full-Time: Monday - Friday, 8 am - 430 pm EST - Comfortable working in a high-volume production environment. - Processing medical record requests by taking calls from patients, insurance companies and attorneys to provide medical record status - Documenting information in multiple platforms using two computer monitors. - Proficient in Microsoft office (including Word and Excel) We offer: Comprehensive onsite/virtual training program followed by job shadowing with an assigned mentor Company equipment will be provided to you (including computer, monitor, virtual phone, etc.) Full Benefits: PTO, Health, Vision, and Dental Insurance and 401k Savings Plan and tuition Assistance Pay ranges for this job title may differ based on location, responsibilities, skills, experience, and other requirements of the role. The estimated base pay range per hour for this role is: $16-$20.60 USD To ensure the safety of patients and staff, many of our clients require post-offer health screenings and proof and/or completion of various vaccinations such as the flu shot, Tdap, COVID-19, etc. Any requests to be exempted from these requirements will be reviewed by Datavant Human Resources and determined on a case-by-case basis. Depending on the state in which you will be working, exemptions may be available on the basis of disability, medical contraindications to the vaccine or any of its components, pregnancy or pregnancy-related medical conditions, and/or religion. This job is not eligible for employment sponsorship. Datavant is committed to a work environment free from job discrimination. We are proud to be an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, sex, sexual orientation, gender identity, religion, national origin, disability, veteran status, or other legally protected status. To learn more about our commitment, please review our EEO Commitment Statement here (************************************************** . Know Your Rights (*********************************************************************** , explore the resources available through the EEOC for more information regarding your legal rights and protections. In addition, Datavant does not and will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay. At the end of this application, you will find a set of voluntary demographic questions. If you choose to respond, your answers will be anonymous and will help us identify areas for improvement in our recruitment process. (We can only see aggregate responses, not individual ones. In fact, we aren't even able to see whether you've responded.) Responding is entirely optional and will not affect your application or hiring process in any way. Datavant is committed to working with and providing reasonable accommodations to individuals with physical and mental disabilities. If you need an accommodation while seeking employment, please request it here, (************************************************************** Id=**********48790029&layout Id=**********48795462) by selecting the 'Interview Accommodation Request' category. You will need your requisition ID when submitting your request, you can find instructions for locating it here (******************************************************************************************************* . Requests for reasonable accommodations will be reviewed on a case-by-case basis. For more information about how we collect and use your data, please review our Privacy Policy (**************************************** .

We welcome both local and remote applicants to apply: While there is a preference for candidates who can work in a hybrid capacity from our Montpelier, VT office, remote candidates located throughout the Northeast will also be fully considered. Not just another job, but an opportunity to work for one of the best insurance companies in the country and reap the rewards that go along with that level of success. We are a 197 year old company that works hard not to act our age; as a result, we have been recognized as one of the; Best Places to Work in Vermont;. An open and collaborative environment, coupled with exceptional compensation and benefits help to make us one of the most attractive employment opportunities in the country. We are seeking a casualty/general liability claims professional to join our team of adjusters to resolve third party liability claims. The ideal candidate has excellent customer service skills, verbal and written communication, is organized, detail oriented, and is well versed in negotiations and legal discussions. An adjuster's license is preferred, but we are willing to train the right candidate. If you have qualifications that you feel would allow you to contribute to the continued success of Vermont Mutual, we'd love to hear from you. How to Apply: Submit cover letter, salary requirements and resume, in strict confidence. Apply Online

As an Examiner-in-Charge (EIC) for the Vermont Department of Financial Regulation, Captive Insurance Division, your primary responsibilities include examinations and ongoing oversight of Vermont domiciled captive insurance companies. Utilizing a risk-focused approach, an EIC leads a team of examiners in evaluating areas of captive insurance company operations and business practices, including corporate governance, strategy, business plan, IT systems, internal controls, financial reporting and regulatory compliance. An EIC also conducts research, is assigned special projects, and conducts annual and quarterly surveillance for a portfolio of companies. An EIC must be self motivated and possess strong time management, organization, critical thinking and communication skills. Who May

Header: ADMA Biologics is a biopharmaceutical company relentlessly committed to creating superior products for immunodeficient patients at risk for infection. It is our devotion to this underserved population that fuels us and our hands-on approach to production and development that sets us apart. If you are looking for a dynamic, innovative, growing company in the biopharmaceutical industry that is committed to excellence and integrity, then consider ADMA Biologics. We currently have an exciting opportunity available for a full time Plasma Processor. Job Title: Plasma Processor : Position Summary The Plasma Processor is responsible for ensuring the product integrity of the plasma unit and associated samples from the time the unit is collected until the unit is shipped. The plasma processor follows SOPs to collect the appropriate samples from the unit and visually inspects the unit for acceptability. This position has the responsibility of ensuring all products and samples are moved to the appropriate storage units within the proper timeline and ensuring the freezer is organized in a manner that allows for the appropriate segregation of units and quick location of products or samples. Additional responsibilities include packing and staging units for plasma shipments, preparing units and samples for biohazard waste shipments, locating units and samples as requested, and assisting on the donor floor. They are routinely the initial point of contact for deliveries due to the location in the building and must contact the proper individuals to notify them of delivery. Responsibilities on the donor room floor include the set-up of automated collection instruments, monitoring of donors through the collection process, disconnection of donors from the automated instrument, and the management of Level 1 reactions. Responsibilities in the screening area include the capability of interpreting the results of the health history and vital signs in relation to the criteria as outlined in the company procedures and ensuring the acceptability of donors following these established procedures. In addition to completing and maintaining the qualification of a plasma processor, cross-training and successful qualification for donor tech and donor screener functions is a standard expectation of the role. The plasma processor must maintain clean efficient work environment, and ensure sufficient operating supplies and forms are available as needed. Follows all FDA and OSHA policies and procedures and maintains confidentiality of all personnel, donor and center information. They also assist with the administrative duties to support the Donor Center and maintain compliance with procedures and regulations while following the current Good Manufacturing Practices (cGMPs). Essential Functions (ES) and Responsibilities Key Duties (E): o Labels and verifies sample tubes, unit label number, and sample tube label number prior to sampling. o Collects all required samples from the unit following ADMA SOP's to ensure that sterility is maintained. o Places units and samples in freezer within 30 minutes of collection. o Completes the entire processing of only one (1) at a time to prevent unit mix ups. o Stores units and samples in accordance with SOPs. o Accurately and efficiently completes all unit, sample packing, and shipping functions. o Physically arranges cases and samples in the freezer to ensure it always remains organized for ease of retrieval of both units and samples. o Perform quality control of areas area equipment. o Obtain any back up samples as required for the laboratory or customers. o Sets-up and readies the collection device correctly. Essential Functions (E) and Responsibilities Collects and labels the required samples at the donor bedside. o Inspects soft goods prior to use to confirm there is no breakage, kinks in the line, contamination, or particles in the solutions. o Correctly maintains, handles, and cleans equipment in accordance with manufacturer's recommendations. o Operates the automated collection device as determined in the user manual. o Monitors the donor for any sign of reaction before, during, and after plasmapheresis. o Disconnects the donor from the automated collection device and ensures the donor is in good physical condition prior to release. o Records information in the collection device as prompted. Records medical incidents as applicable. Records equipment incident information as prompted. o Restocks supplies as necessary. o Reports all unsafe situations or conditions to immediate supervisor or member of center management immediately. o Confirms donor identification in Screening. o Teaches the donor to use the self-administered questionnaire and assist as needed. o Performs donor arm checks. o Determines donor vital signs and weight and properly records results in applicable donor center system. o Determines donor suitability by reviewing donor responses to questionnaire and confirming the donor has provided the correct answers to donor suitability questions. o Defer donors based on knowledge of donor acceptance and deferral criteria. o Explains deferrals and associated time frames to donors. o Respects and maintains donor confidentiality regarding donor deferrals. o Performs donor total protein readings using a refractometer and records the results in n applicable donor center system. o Performs donor hematocrit readings and records the results in applicable donor center system. o Enters required information into the applicable donor center system. o Confirms all required donor suitability criteria and associated records are complete and accurate before determining donor acceptance. o Maintains an organized and clean work environment. o Maintains competence with all position required tasks. o Attends scheduled staff training and staff meetings. o Additional duties as related to/supporting the needs of the business can be assigned by management as deemed necessary. o Perform the function of donor floor technician and other positions based on the needs of the business and at the discretion of leadership. Job Responsibilities or Job Requirements Competencies Demonstrated ability to work well with people from diverse backgrounds Basic computer skills Maintains a professional appearance and demeanor when interacting with peers and donors Demonstrated ability to achieve goals, overcome obstacles, and meet deadlines Managing Time Able to work in high-pressure, deadline-driven environment Experience Requirements * Education Requirements: High school diploma or equivalent required. * Experience Requirements: None Preferred Experience Compliance Requirements (ES) o Executes donor reviews in accordance with SOPs. o Follows all FDA and OSHA policies and procedures and maintains confidentiality of all personnel, donor, and center information. o Performs work duties with strict adherence to procedures and regulations. o Performs job duties and maintains records in accordance with cGMP requirements. Job Description Footer: In addition to competitive compensation, we offer a comprehensive benefits package including:401K plan with employer match and immediate vesting Medical, Vision, Life and Dental InsurancePet InsuranceCompany paid STD and LTDCompany Paid Holidays3 Weeks' Paid Time Off (within the first year) Tuition Assistance (after the first year). To learn more about E-Verify, including your rights and responsibilities, please visit ********************* ADMA Biologics is an Equal Opportunity Employer. Apply now

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

The Plasma Processor is responsible for ensuring the product integrity of the plasma unit and associated samples from the time the unit is collected until the unit is shipped. The plasma processor follows SOPs to collect the appropriate samples from the unit and visually inspects the unit for acceptability. This position has the responsibility of ensuring all products and samples are moved to the appropriate storage units within the proper timeline and ensuring the freezer is organized in a manner that allows for the appropriate segregation of units and quick location of products or samples. Additional responsibilities include packing and staging units for plasma shipments, preparing units and samples for biohazard waste shipments, locating units and samples as requested, and assisting on the donor floor. They are routinely the initial point of contact for deliveries due to the location in the building and must contact the proper individuals to notify them of delivery. Responsibilities on the donor room floor include the set-up of automated collection instruments, monitoring of donors through the collection process, disconnection of donors from the automated instrument, and the management of Level 1 reactions. Responsibilities in the screening area include the capability of interpreting the results of the health history and vital signs in relation to the criteria as outlined in the company procedures and ensuring the acceptability of donors following these established procedures. In addition to completing and maintaining the qualification of a plasma processor, cross-training and successful qualification for donor tech and donor screener functions is a standard expectation of the role. The plasma processor must maintain clean efficient work environment, and ensure sufficient operating supplies and forms are available as needed. Follows all FDA and OSHA policies and procedures and maintains confidentiality of all personnel, donor and center information. They also assist with the administrative duties to support the Donor Center and maintain compliance with procedures and regulations while following the current Good Manufacturing Practices (cGMPs). Essential Functions (ES) and Responsibilities Key Duties (E): o Labels and verifies sample tubes, unit label number, and sample tube label number prior to sampling. o Collects all required samples from the unit following ADMA SOP's to ensure that sterility is maintained. o Places units and samples in freezer within 30 minutes of collection. o Completes the entire processing of only one (1) at a time to prevent unit mix ups. o Stores units and samples in accordance with SOPs. o Accurately and efficiently completes all unit, sample packing, and shipping functions. o Physically arranges cases and samples in the freezer to ensure it always remains organized for ease of retrieval of both units and samples. o Perform quality control of areas area equipment. o Obtain any back up samples as required for the laboratory or customers. o Sets-up and readies the collection device correctly. Essential Functions (E) and Responsibilities Collects and labels the required samples at the donor bedside. o Inspects soft goods prior to use to confirm there is no breakage, kinks in the line, contamination, or particles in the solutions. o Correctly maintains, handles, and cleans equipment in accordance with manufacturer's recommendations. o Operates the automated collection device as determined in the user manual. o Monitors the donor for any sign of reaction before, during, and after plasmapheresis. o Disconnects the donor from the automated collection device and ensures the donor is in good physical condition prior to release. o Records information in the collection device as prompted. Records medical incidents as applicable. Records equipment incident information as prompted. o Restocks supplies as necessary. o Reports all unsafe situations or conditions to immediate supervisor or member of center management immediately. o Confirms donor identification in Screening. o Teaches the donor to use the self-administered questionnaire and assist as needed. o Performs donor arm checks. o Determines donor vital signs and weight and properly records results in applicable donor center system. o Determines donor suitability by reviewing donor responses to questionnaire and confirming the donor has provided the correct answers to donor suitability questions. o Defer donors based on knowledge of donor acceptance and deferral criteria. o Explains deferrals and associated time frames to donors. o Respects and maintains donor confidentiality regarding donor deferrals. o Performs donor total protein readings using a refractometer and records the results in n applicable donor center system. o Performs donor hematocrit readings and records the results in applicable donor center system. o Enters required information into the applicable donor center system. o Confirms all required donor suitability criteria and associated records are complete and accurate before determining donor acceptance. o Maintains an organized and clean work environment. o Maintains competence with all position required tasks. o Attends scheduled staff training and staff meetings. o Additional duties as related to/supporting the needs of the business can be assigned by management as deemed necessary. o Perform the function of donor floor technician and other positions based on the needs of the business and at the discretion of leadership. Job Responsibilities or Job Requirements Competencies Demonstrated ability to work well with people from diverse backgrounds Basic computer skills Maintains a professional appearance and demeanor when interacting with peers and donors Demonstrated ability to achieve goals, overcome obstacles, and meet deadlines Managing Time Able to work in high-pressure, deadline-driven environment Experience Requirements * Education Requirements: High school diploma or equivalent required. * Experience Requirements: None Preferred Experience Compliance Requirements (ES) o Executes donor reviews in accordance with SOPs. o Follows all FDA and OSHA policies and procedures and maintains confidentiality of all personnel, donor, and center information. o Performs work duties with strict adherence to procedures and regulations. o Performs job duties and maintains records in accordance with cGMP requirements. Job Description Footer: Apply now

We welcome both local and remote applicants to apply: While there is a preference for candidates who can work in a hybrid capacity from our Montpelier, VT office, remote candidates located throughout the Northeast will also be fully considered. JOB SUMMARY Directly handle a technical claims caseload of a general liability claims. Caseload typically comprised of files arising from a broad range of coverage or perils and possessing a wide range of financial exposure and complexity. Such claims occasionally involve coverage issues or litigation. Employee should possess demonstrated expertise in handling bodily injury claims which involve both comparative negligence theories and defenses and be able to conclude claims promptly and equitably within the provisions of the policy contract and in accordance with known damages and legal requirements. Litigated files should constitute a minority of pending. All files handled must comply with claim file handling guidelines and all other job expectations, regulations and requirements. DUTIES & RESPONSIBILITIES Conduct and coordinate loss investigations on all assigned claims. Negotiate the settlement of claims within authorized amounts or specific file authority. Maintain accountability for all assigned claims until disposition is reached. Recommend further action to supervisor on claims exceeding authority limits. Document all substantive activity on assigned claims and assist in the control of independent vendors. Review new losses and open files on diary to ensure reserve adequacy while keeping management informed of adverse developments. Monitor loss adjustment expense and take steps to mitigate file expenses. Utilize vendors judiciously to maximize value added. Recognize coverage issues and work with supervisor and claim management for manner of redress/resolution. Refer appropriate coverage matters to the Claim Supervisor or Claim Manager. Ensure appropriate file handling, documentation, reporting and expense control of all files handled inclusive of legal bill review/vendor performance/bill review/MSP compliance Provide accurate, courteous and timely information to all eligible external and internal customers concerning claim status and other claim inquiries. Attend meetings with policyholders and agencies as needed. Draft coverage correspondence in collaboration with Supervisor, including reservation of rights and coverage disclaimer along with composing detailed correspondence to insureds, claimants, attorneys, etc. Attend trials, depositions, EUO's, appraisals and mediations where deemed beneficial or required. Participate in various forms of Litigation training and as a mentee with an assigned Examiner Mentor for litigation and coverage advancement Improve processes within the department to increase the level and quality of service provided to internal and external customers, i.e. workflow changes, systems implementation, etc. Participate in setting file direction and recommend appropriate reserves on claim files within specific authority and on files requiring mandatory reporting to management. This position handles an assigned claim pending. Performs other duties or special projects as required or as assigned. SUPERVISION RECEIVED The Claim Supervisor provides direct minimal supervision. SUPERVISION EXERCISED Primarily no supervisory duties; however limited supervision of independent adjusters and vendors may occur. QUALIFICATIONS Bachelor's degree in business, insurance or a related field, or its equivalent Three or more years of relevant claim technical experience; or a combination of education and experience from which comparable knowledge and skills are acquired. Appropriate state adjuster's license(s) where required by law. Demonstrated commitment to professional development through continuing education related to the job such as AIC, AEI, INS, SCLA CPCU, etc. Established and improving skills in specialized technical disciplines; including working knowledge of relevant insurance, contract and tort law. Participation in training courses and mentorship program Knowledgeable about the insurance industry and company operations. Sound analytical, and negotiations skills. Very good verbal and written communication skills. Ability to exercise sound judgment in dealing with professional and personnel situations. Ability to work effectively with a wide range of outside firms, etc. Ability to collaborate effectively with company management, peers and support staff. Demonstrated customer service orientation. Proficiency with PC applications including Microsoft Office (Word, Excel & Outlook); Experience with imaging and claims handling programs preferred. Ability to perform job duties under stressful situations. PHYSICAL DEMANDS/WORKING CONDITIONS Employees in this job classification may be based in a typical office or a remote location or residence as determined by management. Predominately sedentary office position with high frequency of keyboarding/computer work required. Occasional overnight travel required. Potentially subject to stressful situations with respect to claim dispute. May be exposed to adverse external conditions and inclement Weather. The salary range reflected is a good faith estimate of base pay for the position. In addition to base salary, this role is incentive compensation and benefits eligible, and individual salary will ultimately be determined based on individual experience, skills, qualifications and geographic location.

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

Job Description We welcome both local and remote applicants to apply: While there is a preference for candidates who can work in a hybrid capacity from our Montpelier, VT office, remote candidates located throughout the Northeast will also be fully considered. JOB SUMMARY Directly handle a technical claims caseload of a general liability claims. Caseload typically comprised of files arising from a broad range of coverage or perils and possessing a wide range of financial exposure and complexity. Such claims occasionally involve coverage issues or litigation. Employee should possess demonstrated expertise in handling bodily injury claims which involve both comparative negligence theories and defenses and be able to conclude claims promptly and equitably within the provisions of the policy contract and in accordance with known damages and legal requirements. Litigated files should constitute a minority of pending. All files handled must comply with claim file handling guidelines and all other job expectations, regulations and requirements. DUTIES & RESPONSIBILITIES Conduct and coordinate loss investigations on all assigned claims. Negotiate the settlement of claims within authorized amounts or specific file authority. Maintain accountability for all assigned claims until disposition is reached. Recommend further action to supervisor on claims exceeding authority limits. Document all substantive activity on assigned claims and assist in the control of independent vendors. Review new losses and open files on diary to ensure reserve adequacy while keeping management informed of adverse developments. Monitor loss adjustment expense and take steps to mitigate file expenses. Utilize vendors judiciously to maximize value added. Recognize coverage issues and work with supervisor and claim management for manner of redress/resolution. Refer appropriate coverage matters to the Claim Supervisor or Claim Manager. Ensure appropriate file handling, documentation, reporting and expense control of all files handled inclusive of legal bill review/vendor performance/bill review/MSP compliance Provide accurate, courteous and timely information to all eligible external and internal customers concerning claim status and other claim inquiries. Attend meetings with policyholders and agencies as needed. Draft coverage correspondence in collaboration with Supervisor, including reservation of rights and coverage disclaimer along with composing detailed correspondence to insureds, claimants, attorneys, etc. Attend trials, depositions, EUO's, appraisals and mediations where deemed beneficial or required. Participate in various forms of Litigation training and as a mentee with an assigned Examiner Mentor for litigation and coverage advancement Improve processes within the department to increase the level and quality of service provided to internal and external customers, i.e. workflow changes, systems implementation, etc. Participate in setting file direction and recommend appropriate reserves on claim files within specific authority and on files requiring mandatory reporting to management. This position handles an assigned claim pending. Performs other duties or special projects as required or as assigned. SUPERVISION RECEIVED The Claim Supervisor provides direct minimal supervision. SUPERVISION EXERCISED Primarily no supervisory duties; however limited supervision of independent adjusters and vendors may occur. QUALIFICATIONS Bachelor's degree in business, insurance or a related field, or its equivalent Three or more years of relevant claim technical experience; or a combination of education and experience from which comparable knowledge and skills are acquired. Appropriate state adjuster's license(s) where required by law. Demonstrated commitment to professional development through continuing education related to the job such as AIC, AEI, INS, SCLA CPCU, etc. Established and improving skills in specialized technical disciplines; including working knowledge of relevant insurance, contract and tort law. Participation in training courses and mentorship program Knowledgeable about the insurance industry and company operations. Sound analytical, and negotiations skills. Very good verbal and written communication skills. Ability to exercise sound judgment in dealing with professional and personnel situations. Ability to work effectively with a wide range of outside firms, etc. Ability to collaborate effectively with company management, peers and support staff. Demonstrated customer service orientation. Proficiency with PC applications including Microsoft Office (Word, Excel & Outlook); Experience with imaging and claims handling programs preferred. Ability to perform job duties under stressful situations. PHYSICAL DEMANDS/WORKING CONDITIONS Employees in this job classification may be based in a typical office or a remote location or residence as determined by management. Predominately sedentary office position with high frequency of keyboarding/computer work required. Occasional overnight travel required. Potentially subject to stressful situations with respect to claim dispute. May be exposed to adverse external conditions and inclement Weather. The salary range reflected is a good faith estimate of base pay for the position. In addition to base salary, this role is incentive compensation and benefits eligible, and individual salary will ultimately be determined based on individual experience, skills, qualifications and geographic location.

We welcome both local and remote applicants to apply: While there is a preference for candidates who can work in a hybrid capacity from our Montpelier, VT office, remote candidates located throughout the Northeast will also be fully considered. JOB SUMMARY Directly handle a technical claims caseload of a general liability claims. Caseload typically comprised of files arising from a broad range of coverage or perils and possessing a wide range of financial exposure and complexity. Such claims occasionally involve coverage issues or litigation. Employee should possess demonstrated expertise in handling bodily injury claims which involve both comparative negligence theories and defenses and be able to conclude claims promptly and equitably within the provisions of the policy contract and in accordance with known damages and legal requirements. Litigated files should constitute a minority of pending. All files handled must comply with claim file handling guidelines and all other job expectations, regulations and requirements. DUTIES & RESPONSIBILITIES Conduct and coordinate loss investigations on all assigned claims. Negotiate the settlement of claims within authorized amounts or specific file authority. Maintain accountability for all assigned claims until disposition is reached. Recommend further action to supervisor on claims exceeding authority limits. Document all substantive activity on assigned claims and assist in the control of independent vendors. Review new losses and open files on diary to ensure reserve adequacy while keeping management informed of adverse developments. Monitor loss adjustment expense and take steps to mitigate file expenses. Utilize vendors judiciously to maximize value added. Recognize coverage issues and work with supervisor and claim management for manner of redress/resolution. Refer appropriate coverage matters to the Claim Supervisor or Claim Manager. Ensure appropriate file handling, documentation, reporting and expense control of all files handled inclusive of legal bill review/vendor performance/bill review/MSP compliance Provide accurate, courteous and timely information to all eligible external and internal customers concerning claim status and other claim inquiries. Attend meetings with policyholders and agencies as needed. Draft coverage correspondence in collaboration with Supervisor, including reservation of rights and coverage disclaimer along with composing detailed correspondence to insureds, claimants, attorneys, etc. Attend trials, depositions, EUO's, appraisals and mediations where deemed beneficial or required. Participate in various forms of Litigation training and as a mentee with an assigned Examiner Mentor for litigation and coverage advancement Improve processes within the department to increase the level and quality of service provided to internal and external customers, i.e. workflow changes, systems implementation, etc. Participate in setting file direction and recommend appropriate reserves on claim files within specific authority and on files requiring mandatory reporting to management. This position handles an assigned claim pending. Performs other duties or special projects as required or as assigned. SUPERVISION RECEIVED The Claim Supervisor provides direct minimal supervision. SUPERVISION EXERCISED Primarily no supervisory duties; however limited supervision of independent adjusters and vendors may occur. QUALIFICATIONS Bachelor's degree in business, insurance or a related field, or its equivalent Three or more years of relevant claim technical experience; or a combination of education and experience from which comparable knowledge and skills are acquired. Appropriate state adjuster's license(s) where required by law. Demonstrated commitment to professional development through continuing education related to the job such as AIC, AEI, INS, SCLA CPCU, etc. Established and improving skills in specialized technical disciplines; including working knowledge of relevant insurance, contract and tort law. Participation in training courses and mentorship program Knowledgeable about the insurance industry and company operations. Sound analytical, and negotiations skills. Very good verbal and written communication skills. Ability to exercise sound judgment in dealing with professional and personnel situations. Ability to work effectively with a wide range of outside firms, etc. Ability to collaborate effectively with company management, peers and support staff. Demonstrated customer service orientation. Proficiency with PC applications including Microsoft Office (Word, Excel & Outlook); Experience with imaging and claims handling programs preferred. Ability to perform job duties under stressful situations. PHYSICAL DEMANDS/WORKING CONDITIONS Employees in this job classification may be based in a typical office or a remote location or residence as determined by management. Predominately sedentary office position with high frequency of keyboarding/computer work required. Occasional overnight travel required. Potentially subject to stressful situations with respect to claim dispute. May be exposed to adverse external conditions and inclement Weather. The salary range reflected is a good faith estimate of base pay for the position. In addition to base salary, this role is incentive compensation and benefits eligible, and individual salary will ultimately be determined based on individual experience, skills, qualifications and geographic location.