Claims benefit specialist work from home jobs - 167 jobs

Why work with the OpTech family of companies? We are woman-owned, value your ideas, encourage your growth, and always have your back! When you work with us, you get health and dental benefits, but you also have training opportunities, flexible/remote work options, growth opportunities, 401K and competitive pay. Apply today! Job Title: Workers' Compensation Indemnity Specialist Terms: Direct Hire, FTE Role (Salaried + Benefits + Bonus) We are seeking an experienced Indemnity Claims Specialist to manage a complex workers' compensation desk with a strong emphasis on Kentucky, Indiana, Illinois, and Michigan lost-time and litigated claims. This role handles primarily indemnity and complex files, with limited medical-only exposure, and requires collaboration with internal leadership and external stakeholders to ensure high-quality, compliant claim outcomes. RESPONSIBILITIES: Manage a caseload of approximately 135 open indemnity and complex workers' compensation claims, including lost-time files Handle a desk that is at least 50% litigated, working closely with defense attorneys Demonstrate strong working knowledge of Kentucky & Indiana Workers' Compensation regulations and practices Apply Michigan and Illinois jurisdictional knowledge as required by assigned files Investigate claims, determine compensability, establish reserves, and manage ongoing exposure Coordinate medical care, wage loss benefits, and return-to-work efforts Communicate effectively with all stakeholders, including attorneys, injured workers, employers, carriers, and medical providers Utilize claims management systems to document activity, manage workflows, and meet service expectations Adhere to quality standards, production benchmarks, and client service level agreements (SLAs) Participate in internal reviews, audits, and performance evaluations Performance Measures Compliance with quality and accuracy standards Meeting production expectations for claim handling and resolution Adherence to client service level agreements (SLAs) Stakeholders External: Defense attorneys, injured workers, employers, clients, carriers, medical providers Internal: Supervisor, Manager, Account Manager QUALIFICATIONS: Experience & Knowledge 2-3 years of workers' compensation claims experience, with a strong focus on indemnity and lost-time claims Extensive Kentucky and Indiana workers' compensation experience required Illinois claims experience required Michigan experience preferred and may be eligible for additional consideration Prior experience handling litigated claims is required Licenses & Education Michigan, Indiana, and Kentucky Adjuster's License required Reciprocal licenses (Florida or Texas) accepted Illinois Experienced Examiner Certification Bachelor's degree or equivalent relevant work experience Technical Skills Proficiency in Microsoft Office (Teams, Outlook/Email, Word) Experience using CareMC claims system preferred (not required) Strong documentation, organization, and time-management skills OpTech/GTech is an Equal Opportunity Employer (EOE), all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

Create Music Group is currently looking for self-described viral internet culture enthusiasts to join our Viral Department. Viral Content Claiming Specialist perform administrative tasks such as YouTube copyright claiming and asset onboarding, as well as scope out trending memes and social media videos on a daily basis. This position requires a regular workload of data entry/administration in order to carry out the most basic functions of our department but there are plenty of opportunities for more creative and ambitious pursuits if you are so inclined. This is a full time position which may be done remotely, however our office is located in Hollywood, California, and we are currently only looking for job candidates who are located in California. In the future, you may be encouraged to come into our office for meetings or company functions, so it is best if you are located in the Los Angeles/Southern California area. Through our Viral team, we collaborate with some of the most prominent viral talent from the TikTok and meme world including Supa Hot Fire (Deshawn Raw), Welven Da Great (Deez Nuts), Verbalase, KWEY B, Hoodnews, presidentofugly1, 10k Caash, dimetrees, Zackass, Supreme Patty, The Man with the Hardest Name in Africa, ViralSnare, Adin Ross, and more. YouTube monetization provides an alternative consulting and revenue-generating resource for our clients to grow their audience and earnings. We have helped our clients monetize and collected millions in previously unclaimed revenue for content creators, artists and labels. REQUIREMENTS: 1-3 years work experience Excellent communication skills, both written and verbal Internet culture and social media platforms, especially YouTube Conducting basic level research Organizing large amounts of data efficiently Proficiency with Mac OSX, Microsoft Office, and Google Apps PLUSES: Strong understanding of the online video market (YouTube, Instagram, TikTok) Bilingual - any language, although Spanish, Mandarin, and Russian is preferred RESPONSIBILITIES: We work directly with our clients and their team to help them break down the data and find potential opportunities to build their career. Daily responsibilities include but are not limited to the following. Watching YouTube videos for several hours daily Content claiming Uploading and defining intellectual assets Administrative metadata tasks Researching potential clients Staying on top of accounts for current client roster As this is a remote position, you are required to have your own computer and reliable internet connection. This position may require you to download a great deal of video files (files which may be deleted once onboarding tasks are completed) so please make sure that you have a computer that is up to the task. Laptops are preferable if you would like to come into our office to work (snacks, soft drinks, and Starbucks coffee are provided at our physical office). BENEFITS: Paid company holidays, paid time off, and health benefits (medical, dental, vision, and supplementary policies) are included. TO APPLY: Send us your resume and cover letter (in one file). After you apply, you will be redirected to take our Culture Index survey here. Otherwise, copy and paste the link to your web browser: ********************************************************* Info.php?cfilter=1&COMPANY_CODE=cYEX5Omste Applications without a cover letter and Culture Index survey will not be considered. OPTIONAL: Link relevant social media campaigns and/or writing samples from your portfolio.

Claims Manager (Professional Liability) Counterpart is an insurtech platform reimagining management and professional liability for the modern workplace. We believe that when businesses lead with clarity and confidence, they become more resilient, more innovative, and better prepared for what's ahead. That's why we built the first Agentic Insurance™ system - where advanced AI and deep insurance expertise come together to proactively assess, mitigate, and manage risk. Backed by A-rated carriers and trusted by brokers nationwide, our platform helps small businesses grow with confidence. Join us in shaping a smarter future, helping businesses Do More With Less Risk . As a Claims Manager (Professional Liability), you will be responsible for managing a large and diverse caseload of professional liability claims. In this role, you will apply and further develop your expertise by investigating, evaluating, and resolving claims in a way that reinforces our brand and values. You will also play a vital part in supporting the advancement of our systems and processes through ongoing feedback and collaboration with internal partners. In addition, you will be a key feedback provider for our active claims management processes and systems. Your input will help to shape and improve how we fulfill our mission of providing world-class service through tightly managing legal costs, making data-driven decisions when analyzing a claim's value, and ensuring that other potentially responsible parties pay their fair share. YOU WILL Achieve or exceed claims management case load and goals, applying sound judgment and legal knowledge to produce efficient and fair outcomes. Complete accurate and timely investigations into the coverage, liability, and damages for each claim assigned to you. Actively manage each claim assigned to you in a way that produces the most timely and cost-effective resolution. Build and maintain positive and productive working relationships with internal and external customers, including policyholders, brokers, carrier partners, and Risk Engineers (underwriters). Direct and monitor assignments to experts and outside counsel, and hold those vendors accountable for meeting or exceeding our service standards. Support our data collection efforts and models by effectively using our Agentic Claim Experience (ACE) system to fully and accurately capture critical details about each claim assigned to you. Identify and escalate insights into emerging claims trends across industries, geographies, and key business segments. Offer user-level feedback and insights to support the continuous improvement of our claim handling processes, guidelines, and systems. Ensure that every touchpoint with our insureds and brokers is representative of our brand, mission, and vision. YOU HAVE At least 10 years of professional experience, with at least 5 years of experience litigating or managing professional liability claims. Previous carrier experience is a plus. Bachelor's degree required; law degree (J.D.) and professional designations (RPLU, AIC, etc.) highly preferred. Must possess all required state claim adjuster licenses, or be able to obtain them within 90 days of hire. Proven ability to work both independently on complex matters and collaboratively as a team player to assist others as needed. High level of personal initiative and leadership skills. Exceptional time management, problem solving and organizational skills. Comfort and skill operating in a paperless claims environment. Familiarity with Google Workplace is preferred, but not required. Willingness to quickly adapt to change and use creative thinking and data-driven insights to overcome obstacles to resolution. Strong communication skills, both verbal and written. Ability to succeed in a full remote workplace environment, and travel as necessary (approximately 10-15%). WHO YOU WILL WORK WITH Eric Marler, Head of Claims: An industry veteran, Eric has more than 20 years of experience working with or for insurers offering management liability solutions. He is a licensed attorney who began his career in private practice before transitioning in-house. Prior to joining Counterpart, Eric held leadership roles at Great American Insurance Group and The Hanover Insurance Group. Jaclyn Vogt, Senior Claims Manager: Jaclyn is a licensed adjuster with over 15 years of experience handling Employment Practices Liability, Management Liability and Workers Compensation claims. Jaclyn received her bachelor's degree from Centre College. Katherine Dowling, Claims Manager: Katherine is a licensed attorney, mediator and adjuster with over a decade of experience handling professional liability and management liability litigation and claims. Katherine practiced law for several years with two of Atlanta's largest insurance defense firms prior to joining a wholesale specialty insurance carrier where she managed complex Professional Liability and Commercial General Liability claims. WHAT WE OFFER Stock Options: Every employee is able to participate in the value that they create at Counterpart through our employee stock option plan. Health, Dental, and Vision Coverage: We care about your health and that of your loved ones. We cover up to 100% of your monthly contributions for health, dental, and vision insurance and up to 80% coverage for family members. 401(k) Retirement Plan: We value your financial health and offer a 401(k) option to help you save for retirement. Parental Leave: Birthing parents may take up to 12 weeks of parental leave at 100% of their regular pay following the birth of the employee's child, and can choose to take an additional 4 unpaid weeks. Non-birthing parents will receive 8 weeks of parental leave at 100% of their regular pay. Unlimited Vacation: We offer flexible time off, allowing you to take time when you need it. Work from Anywhere: Counterpart is a fully distributed company, meaning there is no office. We allow employees to work from wherever they do their best work, and invite the team to meet in person a couple times per year. Home Office Allowance: As a new employee, you will receive a $300 allowance to set up your home office with the necessary equipment and accessories. Wellness stipend: $100 per month to spend toward an item or service that supports your wellness (i.e. massage or gym membership, meditation app subscription, etc.) Book stipend: To support your intellectual development, we offer a book stipend that allows you to purchase books, e-books, or educational materials relevant to your role or professional interests. Professional Development Reimbursement: We provide up to $500 annually for you to invest in relevant courses, workshops, conferences, or certifications that will enhance your skills and expertise. No working birthdays: Take your birthday off, giving you the opportunity to relax, enjoy your special day, and spend time with loved ones. Charitable Contribution Matching: For every charitable donation you make, we will match it dollar for dollar, up to a maximum of $150 per year. This allows you to amplify your charitable efforts and support causes close to your heart. COUNTERPART'S VALUES Conjoin Expectations - it is the cornerstone of autonomy. Ensure you are aware of what is expected of you and clearly articulate what you expect of others. Speak Boldly & Honestly - the only failure is not learning from mistakes. Don't cheat yourself and your colleagues of the feedback needed when expectations aren't being met. Be Entrepreneurial - control your own destiny. Embrace action over perfection while navigating any obstacles that stand in the way of your ultimate goal. Practice Omotenashi (“selfless hospitality”) - trust will follow. Consider every interaction with internal and external partners an opportunity to develop trust by going above and beyond what is expected. Hold Nothing As Sacred - create routines but modify them routinely. Take the time to reflect on where the business is today, where it needs to go, and what you have to change in order to get there. Prioritize Wellness - some things should never be sacrificed. We create an environment that stretches everyone to grow and improve, which is fulfilling, but is only one part of a meaningful life. Our estimated pay range for this role is $150,000 to $180,000. Base salary is determined by a variety of factors, including but not limited to, market data, location, internal equitability, and experience. We are committed to being a welcoming and inclusive workplace for everyone, and we are intentional about making sure people feel respected, supported and connected at work-regardless of who you are or where you come from. We value and celebrate our differences and we believe being open about who we are allows us to do the best work of our lives. We are an Equal Opportunity Employer. We do not discriminate against qualified applicants or employees on the basis of race, color, religion, gender identity, sex, sexual preference, sexual identity, pregnancy, national origin, ancestry, citizenship, age, marital status, physical disability, mental disability, medical condition, military status, or any other characteristic protected by federal, state, or local law, rule, or regulation.

5 Years Facets Claims Adjudication Experience The Claims Examiner must maintain production and inventory standards compliant with Claims Administration requirements High school diploma or equivalent required Must have 5+ years of relevant claim processing experience in healthcare industry (managed care or TPA Company) to support our clients Possess high productivity and quality standards within a claims processing automation environment Knowledge of CPT, HCPC, ICD-10 codes Knowledge of HMO, PPO, Medicare and Medicaid plans Knowledge of Medical terminology Computer with 2 Monitors High Speed Internet Connection Ability to work remote 8 hour day, Mon-Fri. Responsibilities: The claims examiner is responsible for accurate and timely adjudication of claims for the Health Plans lines of business Primary duties include analysis and resolution of claims, including reviewing pended claims and manually resolving based on client specified direction and criteria, including third-party liability claims The claims examiner must be able to work independently, effectively prioritizing work in a production environment that frequently changes to meet production standards and contractual requirements Success in this position will be based on the individual's ability to effectively prioritize work, identify, and resolve complex concerns in a professional manner, and work in a team environment to achieve and maintain production and audit standards Timely and accurate processing and adjudication of all types of claims from assigned workflow queues Compliance with state, federal and contractual requirements to Claims Administration Demonstrate a thorough knowledge of the Plan's claims processing procedures as provided in training materials and proficiency with the core and ancillary system applications Demonstrates the ability to think analytically to resolve complicated claim issues and identify appropriately when to escalate issues for review Ability to review and apply Plan directives and desktop procedures to claims, following step by step guidelines Claim analysis of coding and billing compliance, potential third-party liability, accurate coordination of benefits (COB), benefit application including limitations and restrictions, pre-existing conditions, subrogation, medical necessity and other claim investigation as appropriate Complete all mandatory claims training/refresher courses Actively participates and supports department and organization-wide efforts to improve efficiencies while supporting departmental goals and objectives Complete all mandatory compliance and corporate training Must be able to adapt to a changing work priorities and requirements and perform other duties as directed to support the overall functions of Claims Administration and support of staff without boundaries within the Plan

Reliant Health Partners is an innovative medical claims repricing service provider, helping employers achieve maximum health plan savings with minimum noise. We tailor our services to each client's needs, providing everything from individual specialty claims repricing, to full plan replacement as a high-performance, open-access network alternative. As a Medical Claims Appeal Specialist, you are responsible for contacting providers to educate on NSA process/payments, respond to appeals for various products, and negotiate these post pay appealed claims to resolve payment disputes. Primary Responsibilities Monitor and manage your post payment queues. Conduct outreach, education, and negotiation calls to providers for post payment claims. Effectively communicate with providers to verify/confirm understanding of NSA claims payments and regulations. Effectively communicate with providers to explain claim payments for various pricing products. Maintain compliance, including but not limited to Confidentiality and HIPAA requirements. Maintain acceptable levels of production including but limited to turn around time standards as mandated by the regulation(s). Document all conversations and record name, phone number, and email of contact person if available, payment rates offered on behalf of clients, and any counter offers by the provider. Adhere to client specific and Reliant protocols, scripts, and other requirements. Develop a comprehensive understanding of the state and federal regulations that will impact payments to providers. Develop a comprehensive understanding of our various products. Perform other job-related duties and special projects as required. Qualifications 2-3 years of related job experience - appeals, negotiations, medical billing. Experience conducting outreach to providers via phone calls or other communication means. Experience understanding Reliant critical behaviors and compliance requirements. Broad healthcare policy and payment understanding. Experience with claims workflow tools or systems. Individual compensation will be commensurate with the candidate's experience and qualifications. Certain roles may be eligible for additional compensation, including bonuses, and merit increases. Additionally, certain roles have the opportunity to receive sales commissions that are based on the terms of the sales commission plan applicable to the role. Pay Transparency$50,000-$60,000 USDBenefits: Comprehensive medical, dental, vision, and life insurance coverage 401(k) retirement plan with employer match Health Savings Account (HSA) & Flexible Spending Accounts (FSAs) Paid time off (PTO) and disability leave Employee Assistance Program (EAP) Equal Employment Opportunity: At Reliant, we know we are better together. We value, respect, and protect the uniqueness each of us brings. Innovation flourishes by including all voices and makes our business-and our society-stronger. Reliant Health Partners is an equal opportunity employer and we are committed to providing equal opportunity in all of our employment practices, including selection, hiring, performance management, promotion, transfer, compensation, benefits, education, training, social, and recreational activities to all persons regardless of race, religious creed, color, national origin, ancestry, physical disability, mental disability, genetic information, pregnancy, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, and military and veteran status, or any other protected status protected by local, state or federal law.

We are united in our mission to make a positive impact on healthcare. Join Us! South Florida Business Journal, Best Places to Work 2024 Inc. 5000 Fastest-Growing Private Companies in America 2024 2024 Black Book Awards, ranked #1 EHR in 11 Specialties 2024 Spring Digital Health Awards, “Web-based Digital Health” category for EMA Health Records (Gold) 2024 Stevie American Business Award (Silver), New Product and Service: Health Technology Solution (Klara) Who we are: We Are Modernizing Medicine (WAMM)! We're a team of bright, passionate, and positive problem-solvers on a mission to place doctors and patients at the center of care through an intelligent, specialty-specific cloud platform. Our vision is a world where the software we build increases medical practice success and improves patient outcomes. Founded in 2010 by Daniel Cane and Dr. Michael Sherling, we have grown to over 3400 combined direct and contingent team members serving eleven specialties, and we are just getting started! ModMed's global headquarters is based in Boca Raton, FL, with a growing office in Hyderabad, India, and a robust remote workforce across the US, Chile, and Germany. ModMed is hiring a driven Patient Claim Specialist who will play a pivotal role in shaping a positive patient experience within our passionate, high-performing Revenue Cycle Management team. As a critical team member, you will support patients receiving care from ModMed BOOST service providers and doctors, ensuring their account needs are met excellently. This direct interaction with our customers' patients makes you an integral part of ModMed's business. It opens the door to an exhilarating career path for individuals driven by a passion for healthcare and exceptional customer service within a fast-paced Healthcare IT company that is genuinely Modernizing Medicine! Your Role: Serve as primary contact for all inbound and outbound patient calls regarding patient balance inquiries, claims processing, insurance updates, and payment collections Initiate outbound calls to patients of RCM clients to understand and address any account/payment issues, such as demographic and insurance updates Input and update patient account information and document calls into the Practice Management system Special Projects: Other duties as required to support and enhance our customer/patient-facing activities Skills & Requirements: High School Diploma or GED required Availability to work 9:30-5:30pm PST or 11:30am to 8:30 pm EST Minimum of 1-2 years of previous healthcare administration or related experience required Basic understanding of medical billing claims submission process and working with insurance carriers required (e.g., Medicare, private HMOs, PPOs) Manage/ field 60+ inbound calls per day Bilingual is a requirement (Spanish & English) Proficient knowledge of business software applications such as Excel, Word, and PowerPoint Strong communication and interpersonal skills with an emphasis on the ability to work effectively over the telephone Ability and openness to learn new things Ability to work effectively within a team in order to create a positive environment Ability to remain calm in a demanding call center environment Professional demeanor required Ability to effectively manage time and competing priorities #LI-SM2 ModMed Benefits Highlight: At ModMed, we believe it's important to offer a competitive benefits package designed to meet the diverse needs of our growing workforce. Eligible Modernizers can enroll in a wide range of benefits: India Meals & Snacks: Enjoy complimentary office lunches & dinners on select days and healthy snacks delivered to your desk, Insurance Coverage: Comprehensive health, accidental, and life insurance plans, including coverage for family members, all at no cost to employees, Allowances: Annual wellness allowance to support your well-being and productivity, Earned, casual, and sick leaves to maintain a healthy work-life balance, Bereavement leave for difficult times and extended medical leave options, Paid parental leaves, including maternity, paternity, adoption, surrogacy, and abortion leave, Celebration leave to make your special day even more memorable, and company-paid holidays to recharge and unwind. United States Comprehensive medical, dental, and vision benefits 401(k): ModMed provides a matching contribution each payday of 50% of your contribution deferred on up to 6% of your compensation. After one year of employment with ModMed, 100% of any matching contribution you receive is yours to keep. Generous Paid Time Off and Paid Parental Leave programs, Company paid Life and Disability benefits, Flexible Spending Account, and Employee Assistance Programs, Company-sponsored Business Resource & Special Interest Groups that provide engaged and supportive communities within ModMed, Professional development opportunities, including tuition reimbursement programs and unlimited access to LinkedIn Learning, Global presence and in-person collaboration opportunities; dog-friendly HQ (US), Hybrid office-based roles and remote availability for some roles, Weekly catered breakfast and lunch, treadmill workstations, Zen, and wellness rooms within our BRIC headquarters. PHISHING SCAM WARNING: ModMed is among several companies recently made aware of a phishing scam involving imposters posing as hiring managers recruiting via email, text and social media. The imposters are creating misleading email accounts, conducting remote "interviews," and making fake job offers in order to collect personal and financial information from unsuspecting individuals. Please be aware that no job offers will be made from ModMed without a formal interview process, and valid communications from our hiring team will come from our employees with a ModMed email address (*************************). Please check senders' email addresses carefully. Additionally, ModMed will not ask you to purchase equipment or supplies as part of your onboarding process. If you are receiving communications as described above, please report them to the FTC website.

About Us All Care To You is a Management Service Organization providing our clients with healthcare administrative support. We provide services to Independent Physician Associations, TPAs, and Fiscal Intermediary clients. ACTY is a modern growing company which encourages diverse perspectives. We celebrate curiosity, initiative, drive and a passion for making a difference. We support a culture focused on teamwork, support, and inclusion. Our company is fully remote and offers a flexible work environment as well as schedules. ACTY offers 100% employer paid medical, vision, dental, and life coverage for our employees. We also offer paid holiday, sick time, and vacation time as well as a 401k plan. Additional employee paid coverage options available. Job purpose The Claims Examiner III is responsible for the processing and/or adjusting and the releasing of hospital or medical claims according to established policies and procedures. Must identify procedural and system inefficiencies and work with the appropriate entities to resolve issues. Examiners also perform research, analysis, reporting and special projects as assigned. Examiners must be able to meet production requirements and quality standards. Must be able to successfully perform all the duties of the Claims Examiner II. Duties and responsibilities Participate in claims workflow projects. Create and run Crystal /SQL reports for distribution to claims examiners, other department as needed to maintain claims turnaround time compliance. Processing claims for all lines of business including complex claims. Complies with all Company and Department Policies and Procedures. When needed assist in claims audit preparation/activities. Responsible for the processing of claims that are either the financial responsibility of the assigned IPA or capitated Hospital. Must meet quantitative production standard of 100 - 150 claims per day. Must maintain an error accuracy of under 5%. Responsible for validating the diagnosis and procedure codes against the authorized services on Inpatient claims. Responsible for the resolution of Provider Disputes (PDR's) and their documentation (code driven) for required Acknowledgement and Resolution Letters to send to providers. Responsible for requesting additional information required to adjudicate claims, by correctly coding claims notes to generate Development Letters and or Notifications to providers. Responsible for accurately coding claims notes to generate Denial Letters for claims denied as member liability. Ability to resolve claims issues on identified processing errors and make recommendations for improvements to avoid error. Identify any overpayment/underpayment in a review and or history search. Follow department protocol for reporting and following up. Adjusts voids and reopens claims within guidelines to ensure proper adjudication. Resolve any grievances and complaints received through Customer Services, responds when needed to portal/email inquiries and initiates steps to assist regarding issues relating to the content or interpretation of benefits, policies and procedures, provider contracts, and adjudication of claims. Support the Claims Department as business needs require. May have customer/client contact. May assist with training of team members. Works without significant guidance. Identify claims payment errors and/or system configuration flaws during day-to-day operation, report to department manager to correct/resolve them. Able to assist with check run preparation as needed. All other duties as assigned. Qualifications Must have experience with EZ-Cap 10+ years or more experience in processing HMO claims in a managed care environment. Familiar with all regulatory requirements including CMS, DMHC and DHS. Proficient with all Federal and state requirements in claim processing. Knowledge of medical terminology and coding. Proficient in rate application for outpatient PPS & Inpatient DRG facility, ASC, APC, Interim Rate Payment methods to applicable lines of business. (Medicare, Commercial, Medi-Cal). Recognize the difference between Shared Risk and Full Risk claims. Proficient in and knows how to use and apply Health Plan Benefit Matrix and Division of Financial Responsibility. Proficient understanding of AB1324. Proficient understanding of AB1455 Claims Settlement Practice & Dispute and Resolution regulations. Proficiency using Outlook, Microsoft Teams, Zoom, Microsoft Office (including Word and Excel) and Adobe Detail oriented and highly organized Strong ability to multi-task, project management, and work in a fast-paced environment Strong ability in problem-solving Ability to self-manage, strong time management skills. Ability to work in an extremely confidential environment. Strong written and verbal communication skills

--------------------------------------------------------------- The Claims Examiner II is an intermediate level position responsible for the timely review, investigation and adjudication of all types of Medicaid, Medicare, group and individual medical, dental, and mental health claims. Estimated Hiring Range: $22.82 - $27.89 Bonus Target: Bonus - SIP Target, 5% Annual Current CareOregon Employees: Please use the internal Workday site to submit an application for this job. --------------------------------------------------------------- Essential Responsibilities Adjudicate medical, dental and mental health claims in accordance and compliance with plan provisions, state and federal regulations, and CareOregon policies and procedures. Re-adjudicate, adjust or correct claims, including some complex and difficult claims as needed. Consistently meet or exceed the quality and production standards established by the department and CareOregon. Provide excellent customer service to internal and external customers. Collaborate and share information with Claims teams and other CareOregon departments to achieve excellent customer service and support organizational goals. Determine eligibility, benefit levels and coordination of benefits with other carriers; recognize and escalate complex issues to the Lead or Supervisor as needed. Investigate third party issues as directed. May review, process and post refunds and claim adjustments or re-adjudications as needed. Report any overpayments, underpayments or other possible irregularities to the Lead or Supervisor as appropriate. Generate letters and other documents as needed. Proactively identify ways to improve quality and productivity. Continuously learn and stay up to date with changing processes, procedures and policies. Organizational Responsibilities Perform work in alignment with the organization's mission, vision and values. Support the organization's commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals. Strive to meet annual business goals in support of the organization's strategic goals. Adhere to the organization's policies, procedures and other relevant compliance needs. Perform other duties as needed. Experience and/or Education Required § Minimum 2 years' experience as a Medical Claims Examiner or other role that requires knowledge of medical coding and terminology (e.g., medical billing, prior authorizations, appeals and grievances, health insurance customer service, etc.) Preferred Experience using QNXT, Facets, Epic systems Knowledge, Skills and Abilities Required Knowledge Knowledge of CPT, HCPCS, Revenue, CDT and ICD-10 coding Knowledge of medical, dental, mental health and health insurance terminology Skills and Abilities Understanding of or ability to learn state and federal laws and other regulatory agency requirements that relate to medical, dental, mental health and health insurance industry and Medicaid/Medicare industry Ability to perform fast and accurate data entry Strong spoken and written communication skills Basic computer skills (ability to use Microsoft Outlook, Word and Excel) and learn new systems as needed Good customer service skills Ability to participate fully and constructively in meetings Strong analytical and sound problem-solving skills Detail orientation Strong organizational skills and time management skills Ability to work in a fast-paced environment with multiple priorities Ability to work effectively with diverse individuals and groups Ability to learn, focus, understand, and evaluate information and determine appropriate actions Ability to accept direction and feedback, as well as tolerate and manage stress Ability to see, read, hear, speak, and perform repetitive finger and wrist movement for at least 6 hours/day Ability to lift, carry, reach and/or pinch small objects for at least 1-3 hours/day Working Conditions Work Environment(s): ☒ Indoor/Office ☐ Community ☐ Facilities/Security ☐ Outdoor Exposure Member/Patient Facing: ☒ No ☐ Telephonic ☐ In Person Hazards: May include, but not limited to, physical and ergonomic hazards. Equipment: General office equipment Travel: May include occasional required or optional travel outside of the workplace; the employee's personal vehicle, local transit or other means of transportation may be used. Work Location: Work from home Schedule: Monday - Friday, 8:00 AM to 5:00 PM We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package. Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. CareOregon offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks. Please contact your recruiter for more information. We are an equal opportunity employer CareOregon is an equal opportunity employer. The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.

Our client is seeking to add a Commercial Auto Claims Examiner to their team. This individual will be responsible for handling commercial auto liability and physical damage claims from initial intake through resolution. The position involves evaluating coverage, investigating losses, and negotiating settlements across various jurisdictions. This person will have the ability to work fully remote. Key Responsibilities: Investigate, evaluate, and resolve Commercial Auto and Trucking claims from first notice of loss through closure. Review liability, assess damages, and determine appropriate claim strategies. Establish timely and accurate reserves based on claim investigation and exposure. Collaborate with insureds, claimants, attorneys, and vendors to move claims toward resolution. Handle coverage analysis and issue coverage position letters as required. Maintain consistent communication with policyholders and stakeholders throughout the claim lifecycle. Ensure proper file documentation and compliance with company and regulatory standards. Negotiate settlements within authority and in accordance with company/client expectations. Stay current on state-specific laws and regulations related to commercial auto claims. Requirements: 3 - 5+ years of Commercial Auto/Trucking claims handling experience. Active Adjuster's License required. Strong analytical, negotiation, and communication skills. Ability to draft detailed claim reports and correspond professionally with stakeholders. Highly organized, proactive, and able to manage workload independently. Proficient in Microsoft Office and relevant claims management systems. Salary & Benefits: $65,000 - $75,000 annually (depending on experience) Comprehensive Medical, Dental, and Vision coverage 401(k) with company match Paid Time Off and holiday benefits Professional development and career growth opportunities

The Claims Processor will use independent judgement and discretion to review, analyze, and make determinations regarding payment, partial payment, or denial of medical and dental claims, as well as various types of invoices, based upon specific knowledge and application of each client's customized plan(s). ESSENTIAL FUNCTIONS: Process a minimum of 1,200 medical, dental, and vision claims per week while maintaining quality goals. Read, analyze, understand, and ensure compliance with clients' customized plans Learn, adhere to, and apply all applicable privacy and security laws, including but not limited to HIPAA, HITECH and any regulations promulgated thereto. Independently review, analyze and make determinations of claims for: 1) reasonableness of cost; 2) unnecessary treatment by physician and hospitals; and 3) fraud. Review, analyze and add applicable notes using the QicLink system. Review billed procedure and diagnosis codes on claims for billing irregularities. Analyze claims for billing inconsistencies and medical necessity. Authorize payment, partial payment or denial of claim based upon individual investigation and analysis. Review Workflow Manager daily to document and release pended claims, if applicable. Review Pend and Suspend claim reports to finalize all claim determinations timely. Assist and support other Claims Specialists as needed and when requested. Attend continuing education classes as required, including but not limited to HIPAA training. EDUCATION: High School Graduate or equivalent required. EXPERIENCE & SKILLS: Applicants must have a minimum of two (2) years of medical claims analysis experience (Medicare/Medicaid does not count towards the experience) required. Prior experience with a Third-party Administrator (TPA) is highly preferred. Applicants must have knowledge of CPT and ICD-10 coding. Applicants must have strong analytical skills and knowledge of computer systems. Prior experience with dental and vision processing is preferred, but not required. COMPETENCIES Communication Customer Focus Accountability Functional/Technical Job Skills PHYSICAL DEMANDS: Office setting and ability to sit for long periods of time. WORK ENVIRONMENT: Remote Here at Allied, we believe that great talent can thrive from anywhere. Our remote friendly culture offers flexibility and the comfort of working from home, while also ensuring you are set up for success. To support a smooth and efficient remote work experience, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 100Mbps download/25Mbps upload. Reliable internet service is essential for staying connected and productive. The company has reviewed this job description to ensure that essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills, and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate. Compensation is not limited to base salary. Allied values our Total Rewards, and offers a competitive Benefit Package including, but not limited to, Medical, Dental, Vision, Life & Disability Insurance, Generous Paid Time Off, Tuition Reimbursement, EAP, and a Technology Stipend. Allied reserves the right to amend, change, alter, and revise, pay ranges and benefits offerings at any time. All applicants acknowledge that by applying to the position you understand that the specific pay range is contingent upon meeting the qualification and requirements of the role, and for the successful completion of the interview selection and process. It is at the Company's discretion to determine what pay is provided to a candidate within the range associated with the role. Protect Yourself from Hiring Scams Important Notice About Our Hiring Process To keep your experience safe and transparent, please note: All interviews are conducted via video. No job offer will ever be made without a video interview with Human Resources and/or the Hiring Manager. If someone contacts you claiming to represent us and offers a position without a video interview, it is not legitimate. We never ask for payment or personal financial information during the hiring process. For your security, please verify all job opportunities through our official careers page: Current Career Opportunities at Allied Benefit Systems Your security matters to us-thank you for helping us maintain a fair and trustworthy process!

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

SUMMARY DESCRIPTION: The Residential Claims Examiner is responsible for approving and settling residential property claims from the field where an estimate of damage has been prepared, or for preparing and settling estimates, or documenting claims decisions and settling those claims with the policyholder and claimants. The role's primary duties include phone scoping, reviewing coverage, determining settlement amounts, communicating with the policyholder or their representative, and documenting the claim file as outlined by the client or RENFROE. They are also responsible for documenting all activity, submitting required claims documentation, issuing settlement payments, settling and closing the claim using fair claims settlement practices, and ensuring compliance with legal and contractual obligations. REPORTS TO: Assigned RENFROE Manager ESSENTIAL JOB FUNCTIONS: · Follows RENFROE and clients' policies and procedures to handle all assigned property claims · Works with the RENFROE Manager and other adjusters to share knowledge and experience and to gain new skills · Assigns task work for property inspections and interacts with field adjusters and estimators to determine the scope of loss · Oversees claims files for assigned claims and updates claims as new information becomes available using the client's proprietary software · Manages the progression of claims/tasks and claim inventories assigned to them · Contacts and interacts with the policyholder or their representative to obtain documents such as purchase receipts, bills, photographs, or other documents to establish the existence, ownership, and value of the items claimed damaged · Determines coverage and amounts for additional living expenses such as rental housing, travel, meals, etc. · Sets claim reserves following the client's guidelines · Calculates settlement amounts and, within their settlement authority or after receiving requested authority from the client's designee, issues settlement checks with supporting claim documentation · Writes closing reports, including recommendations for the pursuit of subrogation or the disposal of salvage · Reviews the claim file to support and draft coverage decision letters · Maintains required jurisdictional adjusting licenses as required by the client and/or RENFROE · Does not handle claims for which they do not have client authorization or for which they are not licensed · Participates and communicates in client team meetings to discuss claim handling trends, team production, and any claim handling concerns or changes · Makes suggestions on ways to improve process efficiency · Participates in special projects and completes other duties as assigned Non-Authorized Activities: Claims Examiners should not: · Communicate training requirements to client staff adjusters and non-affiliated firms · Communicate training requirements to any claim handler who is not deployed with RENFROE · Discuss Human Resource issues with any client staff adjusters in any segment or any claim handler that is not deployed with RENFROE · Discuss any of the following topics with a client staff adjuster or any claim handler that is not deployed with RENFROE: job openings, termination, prior work history, attendance, absence requests, daily work schedule, claim volume or workload, meal and rest break schedule, promotions, development, compensation, or mentoring of any kind EXPERIENCE/QUALIFICATIONS: · Minimum of 1 year of property claims experience is preferred · Participation in technical insurance coursework is preferred, such as CPCU · Experience using various claims processing systems is preferred · Appropriate licenses, depending on state requirements, and successful completion of required/applicable claims certification training classes · Effective problem resolution and decision-making skills to include analyzing insurance policies and information, demonstrating sound judgment, and utilizing one's own experience and the experience of others · Strong analytical skills and consistent attention to detail · Knowledge of ISO forms, and client policy coverage, procedures, and systems · Communicates clearly and effectively, both verbally and in writing · Strong customer service orientation and good rapport with the insured · Well-organized and hard-working, with the ability to thrive in a fast-paced work environment · Strong interpersonal skills and proven ability to establish good relationships with clients, RENFROE management, employees, and others with whom they interact · Computer skills, including but not limited to practical knowledge of Word and Excel PHYSICAL DEMANDS: · Sitting in a chair for extended periods of time · Ability to operate a telephone, computer, mouse, keyboard, and other similar equipment for extended periods of time · Extended and varying work schedules, which may include work from home or work from a centralized office · Regular attendance required, working up to 12 hours a day, 7 days a week, for extended periods of time, including weekends and holidays · Ability to work in a fast-paced, changing, and multi-tasking environment

Reserv is an insurtech creating and incubating cutting-edge AI and automation technology to bring efficiency and simplicity to claims. Founded by insurtech veterans with deep experience in SaaS and digital claims, Reserv is venture-backed by Bain Capital and Altai Ventures and began operations in May 2022. We are focused on automating highly manual tasks to tackle long-standing problems in claims and set a new standard for TPAs, insurance technology providers, and adjusters alike. We have ambitious (but attainable!) goals and need adjusters who can work in an evolving environment. If building a leading TPA and the prospect of tackling the long-standing challenges of the claims role sounds exciting, we can't wait to meet you. About the role We are seeking a skilled BI-LIT Claims Examiner to manage litigated files and attend trials, conferences, mediations, and arbitrations. The successful candidate will: Investigate and gather all necessary information and documentation related to claims Evaluate liability and damages Negotiate and settle claims Manage litigation cases related to auto claims disputes The BI-LIT Claims Examiner will also be responsible for maintaining electronic files, analyzing defense counsel's performance, and regularly reporting to the Claims Manager. In addition, you will collaborate closely with our product and engineering teams to give feedback and identify technology and process improvements. Who you are Highly motivated and growth-oriented. You're excited by the prospect of building a tech-driven claims org. Passionate adjuster who cares about the customer and their experience. Empathetic. You exercise empathy and patience towards everyone you interact with. Sense of urgency - at all times. That does not mean working at all hours. Creative. You can find the right exit ramp (pun intended) for the resolution of the claim that is in the insured's best interest. Conflict-enjoyer. Conflict does not have to be adversarial, but it HAS to be conversational. Curious. You have to want to know the whole story so you can make the right decisions early and action them to a prompt resolution. Anti-status quo. You don't just wish things were done differently, you action on it. Communicative. (we'd love to know what this means to you) And did we mention, a sense of humor. Claims are hard enough as it is. What we need We need you to do all the things typical to the role: Managing legal aspects of litigated cases, including evaluation of legal process and expenses Analyzing and reviewing auto insurance claims to identify areas of dispute, investigating and gathering all necessary information and documentation related to the claim, evaluating liability and damages related to the claim, and negotiating and settling claims with opposing parties or their insurance providers Managing litigation cases related to auto claims disputes, attending mediations, arbitrations, and court hearings as necessary, and communicating regularly with clients, claims adjusters, attorneys, and other stakeholders Collaborating with defense counsel, claims counsel, and litigation claims management for strategic planning, including developing and maintaining positive working relationships with approved defense firms and other vendors in the industry Reviewing legal documents and ensuring compliance with initial suit-handling plan of action Serving as corporate representative for discovery review and depositions, and appearing as Corporate Representative at depositions and trials when needed Analyzing policy language and reaching appropriate coverage decisions, drafting frequent and complex coverage correspondence, and proactively managing primarily litigated claim files from inception to closure Directing and controlling the activities and costs of numerous outside vendors including defense counsel and coverage counsel, experts and independent adjusters Maintaining adjuster licenses and continuing education requirements Requirements Bachelor's degree (lack of one should not stop you from applying if you possess all the other qualifications) 10+ years of claim handling experience, with 5+ of those years handling a pending of >60% in litigation Transportation litigation (rideshare, auto, trucking, etc) is preferred but those with personal lines experience should still apply if they meet all other requirements. You are not intimidated by an attorney, even if you are not one! You are the driver of the litigation strategy for any particular claim. You manage the discovery in the order and timing of events and hold attorney accountable Understand transportation coverages. Understand contractual risk transfer and additional insured forms You have strong medical knowledge You have a sense of urgency and understanding of how to manage time-sensitive demands Ability and willingness to communicate both on the phone and in written form in a prompt, courteous, and professional manner Strong analytical and negotiation skills. You will conduct your own negotiations directly with opposing counsel Knowledge of multiple state statutes, including good faith claim handling practices, regulations, and guidelines Ability to professionally collaborate with all stakeholders in a claim Have active adjuster license(s) and be willing to obtain all licenses within 45 days, including completing state required testing Attention to detail, time management, and the ability to work independently in a fast-paced, remote environment Curious and motivated by problem solving and questioning the status quo Desire to engage in learning opportunities and continuous professional development Willingness to travel for client and claims needs Benefits Generous health-insurance package with nationwide coverage, vision, & dental 401(k) retirement plan with employer matching Competitive PTO policy - we want our employees fresh, healthy, happy, and energized! Generous family leave policy Work from anywhere to facilitate your work life balance Apple laptop, large second monitor, and other quality-of-life equipment you may want. Technology is something that should make your life easier, not harder! Additionally, we will Provide a manageable pending for you to deliver the service in a way you've always wanted and a dedicated account Listen to your feedback to enhance and improve upon the long-standing challenges of an adjuster Work toward reducing and eliminating all the administrative work from an adjuster role Foster a culture of empathy, transparency, and empowerment in a remote-first environment At Reserv, we value diversity in backgrounds, perspectives, and life experiences and believe that diversity in viewpoints and critical thinking drives innovation, first-principles thinking, and success. We welcome applicants from all backgrounds and encourage those from all walks of life to apply. If you believe you are a good fit for this role, we would love to hear from you!

Job Information State of Tennessee Job Information Opening Date/Time01/27/2026 12:00AM Central TimeClosing Date/Time02/02/2026 11:59PM Central TimeSalary (Monthly)$3,631.00 - $4,533.00Salary (Annually)$43,572.00 - $54,396.00Job TypeFull-TimeCity, State LocationClarksville, TNDepartmentHuman Services LOCATION OF (1) POSITION(S) TO BE FILLED: DEPARTMENT OF HUMAN SERVICES, REHABILITATION SERVICES - DISABILITY DETERMINATION DIVISION, MONTGOMERY COUNTY For more information, visit the link below: ****************************************************************************************************************** This is a remote position Qualifications Education and Experience: Bachelor's degree and two years of full-time professional disability claims examination work. Substitution of Experience for Education: Additional full-time professional disability claims examination work may be substituted for the required education on a year-for-year basis. Necessary Special Qualifications: * Complete a federal background check in accordance with the Homeland Security Presidential Directive 12 (HSPD-12) for issuance of an HSPD-12 compliant Personal Identity Verification (PIV) credential card. Overview This classification performs disability determination work of average difficulty. An employee in this class is responsible for determining adult and child medical eligibility for Social Security Disability, Supplemental Security Income or Medicaid benefits for initial claims in accordance with federal Social Security Administration (SSA) guidelines. This classification performs responsibilities at the working level under general supervision. This class differs from the Sr Disability Claims Examiner in that an incumbent of the latter are responsible adjudication of continuing disability cases and special court ordered or administratively ordered reviews and reviewing claims for compliance with pertinent laws, rules, and regulations. Responsibilities * Determines adult and child medical eligibility for Social Security Disability, Supplemental Security Income or Medicaid benefits using medical, psychiatric, vocational, and educational data for initial and reconsideration claims in accordance with federal Social Security Administration (SSA) guidelines. * Routinely conducts telephone interviews with claimants and others to obtain and/or clarify information on applications. Determines jurisdiction and proper timeframe for requests of claimant records and obtains records from relevant treatment sources. * Independently reviews and analyzes applications, medical assessments, medical records, and vocational assessments as needed for initial and reconsideration claims. Reviews prior decisions for accuracy and development of evidence and examines new allegations or evidence, redetermines medical eligibility, and issues reconsideration decisions. * Documents case notes, appointments, and general correspondence for review and adjudication. Organizes and enters claimant documentary evidence and claim decisions into an electronic case management folder. * Assesses claimant's medical conditions to identify impairments, onset issues, and limitations by reviewing medical records, statements, and other pertinent information to prepare a medical assessment. * Routinely confers with internal medical consultants and various other subject matter experts to ensure all aspects of disability claims are in accordance with federal guidelines. Selects, composes, and sends proper federal disability determination notices to claimants explaining medical and vocational decision issues to claimants and authorized representatives. * Schedules/reschedules consultative examination appointments for claimants and notifies claimants, third parties, attorneys of appointment time and date, and documents reasons for any missed exams. Authorizes payments for examinations and claimant travel. * Reviews claimant's work history to determine if claimant's past work description is adequate and contacts claimant by phone if additional work history is needed. Identifies and analyzes claimant's past relevant work by researching jobs and earnings reported to SSA and compares the claimant's residual capacity with the functional requirements of the claimant's past and other work. Competencies (KSA's) Competencies: * Customer Focus * Resourcefulness * Communicates Effectively * Instills Trust * Situational Adaptability Knowledges: * Customer and Personal Service * Medicine and Dentistry Skills: * Active Learning and Listening * Service Orientation * Critical Thinking * Judgment and Decision Making * Time Management Abilities: * Deductive Reasoning * Inductive Reasoning * Problem Sensitivity * Written Comprehension Tools & Equipment * General Office Equipment * Computer/Laptop/Tablet * Multifunction Printer (Print/Copy/Scan/Fax) * Cell Phone

Title: Claims Examiner Team Leader Job Type: Full-time Work Set-up: Remote Pay: up to $22.00 per hour DOE Work Schedule: Monday-Friday 5:00am to 2:00pm PST | 8:00am-5:00pm EST Position Summary The Claims Examiner Team Leader is responsible for leading and managing a team of claims examiners to ensure accurate, compliant, and timely processing of medical claims. This role serves as a critical bridge between frontline operations and leadership, driving performance against SLAs, quality standards, and productivity targets. The Team Lead is accountable for team performance, coaching and development, and continuous process improvement while ensuring adherence to Medicare regulations and CMS guidelines. Key Responsibilities Team Leadership & Performance Management Personal Production 50% of the time, Lead, supervise, and support a team of 15-20+ claims examiners. Provide ongoing coaching, mentoring, and real-time feedback to improve quality, accuracy, and productivity. Conduct regular performance evaluations and goal setting. Foster a culture of accountability, engagement, integrity, and continuous improvement. Claims Operations Oversight Oversee day-to-day medical claims processing for professional, facility, adjustments, corrected and adjustment claims. Ensure compliance with Medicare requirements, CMS guidelines, client policies, and Imagenet standards. Monitor and manage service level agreements (SLAs), turnaround times, and production. Quality Assurance & Compliance Apply deep working knowledge of CMS regulations, Medicare auditing standards, and payer guidelines. Review claims and audit results to identify trends, root causes, and training opportunities. Ensure consistent application of quality standards by partnering with other team leads to reduce error rates across the team. Reporting, Metrics & Business Reviews Analyze and manage key performance indicators including quality scores, error rates, productivity, attendance, and rework. Prepare and present operational and business reviews using accurate data and client feedback. Identify operational risks, performance gaps, and improvement opportunities and escalate as appropriate. Process Improvement & Cross-Functional Collaboration Identify process inefficiencies and implement improvement strategies to increase accuracy, efficiency, and cost effectiveness. Assist with QA, Training, IT, and Operations leadership to resolve technical or workflow issues. Support implementation of new policies, tools, workflows, and client requirements. Communication & Client Support Maintain clear, timely communication with leadership regarding team performance and operational risks. Address employee concerns and team conflicts professionally and promptly. Escalate client issues or compliance concerns to management immediately when identified. Engagement & Recognition Recognize and reward strong performance and team achievements. Promote teamwork, professionalism, and a positive attitude within the team. Measures of Success / Key Performance Indicators Claims quality and audit results both for personal performance and team performance Error rates and rework reduction both for personal performance and team performance Productivity (claims per day/hour) both for personal performance and team performance Turnaround time / time to completion both for personal performance and team performance Compliance with CMS, Medicare, Medi-Cal, and client guidelines Attendance and reliability both for yourself and your team Client satisfaction and assessment outcomes Team engagement, coachability, and retention Cost efficiency and margin impact Required Qualifications Min. 5 years of experience processing easy, moderate, and complex medical claims. 2+ years in a leadership role within claims or healthcare operations. Strong experience with Medicare and Medi-Cal claims, including a working knowledge of CMS guidelines and regulatory requirements. Prior quality assurance and training experience with demonstrated ability to identify trends Previous experience leading, coaching, or mentoring teams in a claims or healthcare operations environment. Strong analytical skills with the ability to interpret performance data and KPIs. Excellent communication, organizational, and decision-making skills. High attention to detail and commitment to accuracy, compliance, and operational excellence. What We Offer Remote work offered Equipment provided Paid training to set you up for success Comprehensive benefits: Medical, Dental, Vision, Life, HSA, 401(k) Paid Time Off (PTO) 7 paid holidays A supportive team and a company that values internal growth Ready to Grow Your Career? We'd love to meet you! Click “Apply Now” and tell us why you'd be a great addition to the Imagenet team. About Imagenet, LLC Imagenet is a leading provider of back-office support technology and tech-enabled outsourced services to healthcare plans nationwide. Imagenet provides claims processing services, including digital transformation, claims adjudication and member and provider engagement services, acting as a mission-critical partner to these plans in enhancing engagement and satisfaction with plans' members and providers. The company currently serves over 70 health plans, acting as a mission-critical partner to these plans in enhancing overall care, engagement and satisfaction with plans' members and providers. The company processes millions of claims and multiples of related structured and unstructured data elements within these claims annually. The company has also developed an innovative workflow technology platform, JetStreamTM, to help with traceability, governance and automation of claims operations for its clients. Imagenet is headquartered in Tampa, operates 10 regional offices throughout the U.S. and has a wholly owned global delivery center in the Philippines.

Liberty Mutual has an immediate opening for a Complex Claims Specialist with Managed Care, Errors & Omissions (E&O) and Directors & Officers (D&O) Professional Liability claims experience. The Complex Claims Specialist, with minimal supervision, handles a book of specialty lines claims under E&O and D&O policies issued to health plans and other Managed Care Organizations throughout the entire claim's life cycle. In this role, you will be responsible for conducting investigations, evaluating coverage, setting adequate reserves, monitoring, documenting, and settling/closing claims in an expeditious and economical manner within prescribed authority limits for the line of business. *This position may have an in-office requirement and other travel needs depending on candidate location. If you reside within 50 miles of one of the following offices, you will be required to go to the office twice a month: Boston, MA; Hoffman Estates, IL; Indianapolis, IN; Lake Oswego, OR; Las Vegas, NV; Plano, TX; Suwanee, GA; Chandler, AZ; Westborough, MA; or Weatogue, CT. Please note this policy is subject to change. Responsibilities Analyzes, investigates and evaluates the loss to determine coverage and claim disposition. Utilizes proprietary claims management system to document claims and to diary future events or follow up. Issue detailed coverage position letters for all new claims within prescribed time frames. Within prescribed settlement authority, establishes appropriate reserves for both indemnity and expense and reviews on a regular basis to ensure adequacy. Makes recommendations to set reserves at appropriate level for claims outside of authority level. Prepares comprehensive reports as required. Identifies and communicates specific claim trends and account and/or policy issues to management and underwriting. Manages the litigation process through the retention of counsel. Adheres to the line of business litigation guidelines to include budget, bill review and payment. Pro-actively manages the case resolution process. Actively participates in mediations and arbitrations, as well as negotiation discussions within limit of settlement authority. Participates in the claims audit process. Provides claims marketing services by meeting with brokers and insureds. As required, maintains insurance adjuster licenses Qualifications Bachelors' and/or advanced degree 7 + years claims/legal experience, with at least 2 years within a technical specialty preferred Professional Liability (Managed Care, Errors & Omissions and Directors & Officers) Advanced knowledge of claims handling concepts, practices and techniques, to include but not limited to coverage issues, and product line knowledge Functional knowledge of law and insurance regulations in various jurisdictions Demonstrated advanced verbal and written communications skills Demonstrated advanced analytical, decision making and negotiation skills About Us Pay Philosophy: The typical starting salary range for this role is determined by a number of factors including skills, experience, education, certifications and location. The full salary range for this role reflects the competitive labor market value for all employees in these positions across the national market and provides an opportunity to progress as employees grow and develop within the role. Some roles at Liberty Mutual have a corresponding compensation plan which may include commission and/or bonus earnings at rates that vary based on multiple factors set forth in the compensation plan for the role. At Liberty Mutual, our goal is to create a workplace where everyone feels valued, supported, and can thrive. We build an environment that welcomes a wide range of perspectives and experiences, with inclusion embedded in every aspect of our culture and reflected in everyday interactions. This comes to life through comprehensive benefits, workplace flexibility, professional development opportunities, and a host of opportunities provided through our Employee Resource Groups. Each employee plays a role in creating our inclusive culture, which supports every individual to do their best work. Together, we cultivate a community where everyone can make a meaningful impact for our business, our customers, and the communities we serve. We value your hard work, integrity and commitment to make things better, and we put people first by offering you benefits that support your life and well-being. To learn more about our benefit offerings please visit: *********************** Liberty Mutual is an equal opportunity employer. We will not tolerate discrimination on the basis of race, color, national origin, sex, sexual orientation, gender identity, religion, age, disability, veteran's status, pregnancy, genetic information or on any basis prohibited by federal, state or local law. Fair Chance Notices California Los Angeles Incorporated Los Angeles Unincorporated Philadelphia San Francisco We can recommend jobs specifically for you! Click here to get started.

Handshake is seeking experienced Claims Specialists to support AI research through flexible, hourly contract work. This is not a traditional full-time claims role. You'll use your real-world experience investigating, evaluating, and resolving claims to evaluate AI-generated content and provide feedback that helps AI better understand claims processes, policy language, and customer communication. This is an ongoing, project-based opportunity that can be done alongside your primary employment. Who This Is For This project is designed for professionals who are already working (or have recently worked) in roles such as: Claims Specialist or Claims Representative Claims Adjuster (property, casualty, auto, health, disability, or workers' compensation) Claims Examiner or Claims Analyst Senior customer service professional with a strong claims focus This is not a traditional full-time role. You'll apply once and, if qualified, be considered for part-time, project-based work as new projects become available. What You'll Do This project involves using your professional experience as a Claims Specialist to design job-related questions and review AI-generated responses for accuracy and relevance to real-world claims handling and customer interactions. No prior AI or technical experience is required. Qualifications We're looking for established professionals with: 4+ years of professional experience in claims handling or closely related roles Hands-on experience investigating claims, interpreting policy coverage, and communicating decisions to claimants or stakeholders Strong written communication skills and attention to detail Comfortable working independently and following written guidelines Professional judgment, reliability, and a high standard of discretion and confidentiality, especially with sensitive or proprietary information. Work Model and Project Details Status: Independent contractor (not a full-time employee role) Location: Fully remote; work from anywhere with a reliable internet connection and access to a desktop or laptop computer Schedule: Flexible and asynchronous, with no minimum hour requirement. Many contributors work approximately 5-20 hours per week when assigned to an active project Duration: The Handshake AI program runs year-round, with projects opening periodically across different areas of expertise. Placement depends on current project needs, with opportunities to be considered for future projects as they become available Work authorization information F-1 students who are eligible for CPT or OPT may be eligible for projects on Handshake AI. Work with your Designated School Official to determine your eligibility. If your school requires a CPT course, Handshake AI may not meet your school's requirements. STEM OPT is not supported. For more information on what types of work authorizations are supported on Handshake AI.

About the Role At Equitable, we help clients secure their financial well-being so they can pursue long and fulfilling lives- a mission we've honed since 1859. Equitable is looking for an experienced Claims Specialist supporting Disability and Leave Management claims to join our team! The Claims Specialist is responsible for providing excellent customer service. You will be expected to utilize judgment and assess risk as you work with various business partners to render claim decisions and partner with internal and external resources. Reliability and dependability throughout our extensive training program is required. What You'll Be Doing * Deliver an exceptional customer experience and ensure that customer commitments and deliverables are achieved * Communication via telephone, email, and text with employees, employers, attorneys, and others * Review and interpret medical records, utilizing resources as appropriate * Complete financial calculations * Gain an understanding and working knowledge of the Equitable claim and other applicable systems, policies, procedures, and contracts as well as regulatory and statutory requirements for claim adjudication * Apply contract/policy provisions to ensure accurate eligibility and liability decisions * Demonstrate and apply analytical and critical thinking skills * Verify on-going liability and develop strategies for return-to-work opportunities as appropriate * Document objective, clear and technical rationale for all claim determinations and demonstrate the ability to effectively communicate claim decisions to our customers via oral and written communication * Leverage a broad spectrum of resources, materials, and tools to render claims decisions * Provide timely and exceptional customer experience by paying appropriate claims accurately and timely, responding to all inquiries and maintaining expected service and quality standards * Work within a fast-paced environment, with tight deadlines, and demonstrate the ability to balance multiple priorities * Work independently as well as within a team structure This position offers a remote work schedule that allows you to stay fully engaged with your team to provide outstanding, customer‑focused service during our core hours (8:30 AM-5:30 PM EST). Periodic office visits may be requested based on business needs. The base salary range for this position is $50,000-$60,000. Actual base salaries vary based on skills, experience, and geographical location. In addition to base pay, Equitable provides compensation to reward performance with base salary increases, spot bonuses, and short-term incentive compensation opportunities. Eligibility for these programs depends on level and functional area of responsibility. For eligible employees, Equitable provides a full range of benefits. This includes medical, dental, vision, a 401(k) plan, and paid time off. For detailed descriptions of these benefits, please reference the link below. Equitable Pay and Benefits: Equitable Total Rewards Program What You Will Bring * Bachelor's degree or equivalent work experience * 1 years disability claims experience * Exceptional customer service skills * Maintains positive and effective interaction with challenging customers * Strong knowledge of disability and leave laws and regulations * Ability to handle sensitive information with confidentiality and professionalism Preferred Qualifications * Group Disability Claims experience * Exceptional written and oral communication skills demonstrated in previous work experience * Excellent organizational and time management skills with ability to multitask and prioritize deadlines * Ability to manage multiple and changing priorities * Detail oriented; able to analyze and research contract information * Demonstrated ability to operate with a sense of urgency * Experience in effectively meeting/ exceeding individual professional expectations and team goals * Demonstrated analytical and math skills * Ability to exercise critical thinking skills, risk management skills and sound judgment * Ability to adapt, problem solve quickly and communicate effective solutions * High level of flexibility to adapt to the changing needs of the organization * Self-motivated, independent with proven ability to work effectively on a team and work with others in a highly collaborative team environment * Continuous improvement mindset * A commitment to support a work environment that fosters diversity and inclusion * Proficiency in computer literacy and skills with the ability to work within multiple systems; proficiency with PC based programs such as Excel and Word Skills Analytical Thinking: Knowledge of techniques and tools that promote effective analysis; ability to determine the root cause of organizational problems and create alternative solutions that resolve these problems. Customer Support Operations: Knowledge of customer support techniques, tools, technologies, and best practices; ability to utilize all aspects of customer support operations to manage a call center. Customer Support Systems: Knowledge of principles and techniques used in customer support and ability to use applications, hardware, software, networking, and the applications environment used for customer support. Managing Multiple Priorities: Knowledge of effective self-management practices; ability to manage multiple concurrent objectives, projects, groups, or activities, making effective judgments as to prioritizing and time allocation. Problem Solving: Knowledge of approaches, tools, techniques for recognizing, anticipating, and resolving organizational, operational or process problems; ability to apply knowledge of problem solving appropriately to diverse situations. #LI-Remote About Equitable At Equitable, we're a team committed to helping our clients secure their financial well-being so that they can pursue long and fulfilling lives. We turn challenges into opportunities by thinking, working, and leading differently - where everyone is a leader. We encourage every employee to leverage their unique talents to become a force for good at Equitable and in their local communities. We are continuously investing in our people by offering growth, internal mobility, comprehensive compensation and benefits to support overall well-being, flexibility, and a culture of collaboration and teamwork. We are looking for talented, dedicated, purposeful people who want to make an impact. Join Equitable and pursue a career with purpose. Click Careers at Equitable to learn more. Equitable is committed to providing equal employment opportunities to our employees, applicants and candidates based on individual qualifications, without regard to race, color, religion, gender, gender identity and expression, age, national origin, mental or physical disabilities, sexual orientation, veteran status, genetic information or any other class protected by federal, state and local laws. NOTE: Equitable participates in the E-Verify program. If reasonable accommodation is needed to participate in the job application or interview process or to perform the essential job functions of this position, please contact Human Resources at ************** or email us at *******************************.

ERGO NEXT's mission is to help entrepreneurs thrive. We're doing that by building the only technology-led, full-stack provider of small business insurance in the industry, taking on the entire value chain and transforming the customer experience. Simply put, wherever you find small businesses, you'll find ERGO NEXT. Since 2016, we've helped hundreds of thousands of small business customers across the United States get fast, customized and affordable coverage. We're backed by industry leaders in insurance and tech, and we still have room to grow - that's where you come in. As a Claims Specialist, you will be deemed a subject matter expert in the Claims department. Your extensive experience in commercial claims will allow you to handle high-severity and high-complexity claims. You will also lead department roundtables and have the opportunity to serve as a valuable peer resource to other team members! What You'll Do: Extensive policy document and legal contract interpretation Ability to analyze and identify coverage and related coverage issues Leverage a working knowledge of insurance contracts, Unfair Claims Settlement Practices, insurance codes, civil codes, vehicle codes, arbitration rules and regulations, tort law, claims best practices handling and management as part of your ongoing adjudication of claims Manage, investigate, and resolve claims within prescribed authority levels Recommend ultimate resolution on assigned cases in excess of authority to claims management Rely on a deep background of litigation handling experience in both General Liability and Casualty files to resolve claims Consistently drive litigation, attend mediations, trials, and other alternative dispute resolution avenues Communicate with policyholders, witnesses, and claimants in order to gather information regarding claims, refer tasks to auxiliary resources as necessary, and advise as to the proper course of action Preemptively communicate and respond to various written (email, SMS, fax, mail) and telephone inquiries, including status reports Present file materials for authority and roundtables Work with nurses, doctors, and attorneys on file reviews Comply with all statutory and regulatory requirements of all applicable jurisdiction Meet detailed quality assurance standards and meet set goals for performance Set and revise case reserves in accordance with the reserving policy Identify potentially suspicious claims and refer to SIU; identify opportunities for third-party subrogation Be accountable for the security of the financial processing of claims, as well as security information contained in claims files Work with, and provide claim-specific guidance to, independent field adjusters Partner closely with internal teams and advise leadership of key claim activities and exposures What We Need: BS/BA Degree required Advanced studies or insurance designation preferred At least 15+ years of directly related experience with Commercial General Liability and Litigation Strong written and oral communication skills required, as well as strong interpersonal, analytical, investigative, and negotiation skills In-depth knowledge of multi-jurisdictional claims handling issues Willingness to utilize and adapt to evolving technologies within the Claims operations Must be a self-starter and able to work independently Candidates must have, or be able to promptly obtain, a Texas Independent Adjuster License Effective communication, presentation, negotiation, and persuasion skills Ability to collaborate with cross-functional teams to achieve business results Proven success in delivering strong results in a rapidly changing claims environment Someone who achieves a standard of excellence with work processes and outcomes, honoring company policies and regulatory compliance Team orientation that emphasizes building strong working relationships and contributing to a positive work environment High degree of comfort with navigating sometimes ambiguous environments and a willingness to dive in and assist coworkers with workloads or contribute to organizational needs/projects when needed Receptivity to feedback and a willingness to learn, embracing continuous improvement, and having an openness to learning new and evolving proprietary and off-the-shelf software systems Some travel capability, likely up to 10% of capability Note on Fraudulent Recruiting We have become aware that there may be fraudulent recruiting attempts being made by people posing as representatives of Ergo Next Insurance. These scams may involve fake job postings, unsolicited emails, or messages claiming to be from our recruiters or hiring managers. Please note, we do not ask for sensitive information via chat, text, or social media, and any email communications will come from the *************************. Additionally, Next Insurance will never ask for payment, fees, or purchases to be made by a job applicant. All applicants are encouraged to apply directly to our open jobs via the careers page on our website. Interviews are generally conducted via Zoom video conference unless the candidate requests other accommodations. If you believe that you have been the target of an interview/offer scam by someone posing as a representative of Ergo Next Insurance, please do not provide any personal or financial information. You can find additional information about this type of scam and report any fraudulent employment offers via the Federal Trade Commission's website (********************************************* or you can contact your local law enforcement agency. The range displayed on this job posting reflects the minimum and maximum target for new hire salaries for the position across all US locations. Within the range, individual pay is determined by work location and additional factors, including, without limitation, job-related skills, experience, and relevant education or training. NEXT employees are eligible for our benefits package, consisting of our partially subsidized medical plan, fully subsidized vision/dental options, life insurance, disability insurance, 401(k), flexible paid time off, parental leave and more. US annual base salary range for this full-time position:$100,000-$130,000 USD Don't meet every single requirement? Studies have shown that some underrepresented people are less likely to apply to jobs unless they meet every single qualification. At NEXT, we are dedicated to building a diverse, inclusive and respectful workplace, so if you're excited about this role but your past experience doesn't align perfectly with every qualification in the job description, we encourage you to apply anyways. You may be just the right candidate for this or other roles. One of our core values is 'Play as a Team'; this means making sure everyone has an equal chance to participate and make a difference. We win by playing together. Next Insurance is an equal opportunity employer and prioritizes building a diverse and inclusive workplace. We provide equal employment opportunities to all employees and applicants of any type and do not discriminate based on race, color, religion, national origin, gender, age, sexual orientation, physical or mental disability, genetic information or characteristic, gender identity and expression, veteran status, or other non-job-related characteristics or other prohibited grounds specified in applicable federal, state, and local laws. Next's policy is to comply with all applicable laws related to nondiscrimination and equal opportunity and will not tolerate discrimination or harassment based on any of these characteristics. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.