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Claim Specialist jobs at Public Consulting Group - 1937 jobs

  • Casualty Claims Adjuster

    The Jacobson Group 4.9company rating

    Hingham, MA jobs

    Responsibilities: Conduct in-depth investigations into complex bodily injury claims, determining coverage, establishing liability, and evaluating damages by analyzing medical records, police reports, and witness statements. Develop and execute effective negotiation strategies to achieve fair and timely settlements with claimants, attorneys, and other parties. Manage litigated files, including developing defense strategies, communicating with legal counsel, and attending mediations, arbitrations, and trials as necessary. Maintain meticulous and accurate claim file documentation in compliance with company standards and regulatory requirements. Provide exceptional customer service, guiding insureds and claimants through complex claim processes with professionalism and empathy. Candidate & SkillsTop 3-5 Skills: 5 + years of direct experience handling casualty claims, with a strong focus on bodily injury (BI) claims across various lines (Auto, Homeowners, Commercial). Proven ability to investigate, analyze, and evaluate complex BI claims, including understanding medical terminology and injury causation. Solid understanding of insurance policies, relevant state laws, and the litigation process. Strong negotiation and conflict resolution skills, with a track record of successful settlements. Takes ownership of files, even when litigation is involved. Soft Skills: Exceptional communication (verbal and written), interpersonal, and customer service skills. Ability to work independently, manage a challenging caseload, and make sound judgments. Strong analytical, problem-solving, and decision-making abilities. Meticulous attention to detail and excellent organizational skills. An eagerness to learn, adapt, and embrace new technologies Ability to work effectively both independently and as part of a supportive team. Certifications/Licenses/Education: Active Adjuster License in CT, MA, RI - willing to get additional licenses as needed (company to assist) A bachelor's degree is preferred, or equivalent work experience. Pay Range: $80,000-$100,000 We understand salary is an important factor in your job search and encourage you to apply even if your desired compensation falls outside this range. The final rate is determined based on several factors including relevant experience, education, certifications, and market conditions. Benefits: Our comprehensive benefits package includes: o Medical insurance o Dental insurance o Vision insurance o 401(k) retirement savings plan Contact: Justine Haley ************************ Refer a Colleague: Do you know someone who would be interested in this project? Submit your referral directly by emailing the Jacobson contact listed above or submitting them through this form. If your referral is hired for a contract assignment and meets all other eligibility criteria, you will receive a referral bonus! Equal Opportunity Employer: The Jacobson Group is committed to fostering an inclusive and equitable workplace that reflects the diverse communities we serve. We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status or any other protected characteristic as defined by applicable law. We believe that diversity of thought, background and experience strengthens our team and drives innovation. All employment decisions are based on qualifications, merit and business needs. If you require a reasonable accommodation to complete the application process or participate in an interview, please contact us at ********************* or ***************** to make a request.
    $80k-100k yearly 2d ago
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  • Automotive Claims Adjuster

    Ascendo Resources 4.3company rating

    Jacksonville, FL jobs

    Verify claim information to determine if the customer's concern, diagnosis, and failure justify the repair approval within the terms of the contract. Verify repair costs are performed within industry standards. Verify repair information to determine if coverage was within the limits of the service contract. Interface with customers, agents, dealers to complete all investigations of claims. Complete a fair settlement of the claim. Contribute to team effort by accomplishing related results as needed. Verify claims are processed following the policy and procedure established by Smart Autocare Periodic Job Functions Participate in any projects, reports, documentation, tasks or objectives assigned Skills & Competencies Required Parts and Labor Guide familiarity. Intermediate knowledge of Windows-based computer programs. Exceptional customer service and communication skills. Ability to read, analyze and interpret general business correspondence or technical procedures. Ability to solve practical problems and deal with a variety of concrete variables in situations where limited standardization exists Spanish fluency/Bilingual a plus Adhere closely to a posted schedule
    $43k-52k yearly est. 3d ago
  • Workers Compensation Indemnity Adjuster

    Optech 4.6company rating

    Downers Grove, IL 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.
    $50k-66k yearly est. 3d ago
  • Member Claims Associate

    Cypress HCM 3.8company rating

    Lehi, UT jobs

    Medical Claims Associate What You'll Do Execute the daily operations of a health plan, including processing medical claims, researching and responding to our members' most complicated questions, tracking your accuracy around core metrics, and troubleshooting the many operational challenges that affect our business Be part of the team that is continuously adapting to improve efficiency and scalability Think critically and strategically to continually boost teamwork and communication across offices Gain additional skills across different areas of our business over time Develop in-depth industry expertise in the healthcare economy Cultivate a culture that aligns with our values and incorporates the unique aspects of our team Reporting to the Manager of Member Claims, this is an essential role on our Customer Experience team To be successful in this role, you'll need: Above all, you are driven, curious, and take ownership for everything you do You can become proficient with a large volume of information quickly You are a committed team player You are excited to build and adapt to the adventures of working on a growing team You are passionate about being a part of a fast-growing company You have a passion for our mission to transform the health insurance experience for employers and their employees Nice to have: Bachelor's degree or 1 or more years of work experience Compensation: $21.50 per hour
    $21.5 hourly 3d ago
  • Mechanical Vehicle Claims Adjuster

    Ascendo Resources 4.3company rating

    Jacksonville, FL jobs

    Vehicle Claims Adjuster 📍 On-site | Full-Time 🚗 From the dealership or shop floor to the office - without leaving automotive behind. We're hiring a Vehicle Claims Adjuster to join our in-office claims team. This role is ideal for professionals with experience as a Service Advisor, Technician, Warranty Administrator, or Claims Adjuster who want to leverage their automotive knowledge in a stable, professional claims environment. In this role, you'll evaluate mechanical failures, review repair estimates, and determine coverage under vehicle service contracts (VSCs), while working closely with repair facilities, dealerships, inspectors, and internal teams. What You'll Do Investigate, evaluate, and adjudicate mechanical and vehicle service contract (VSC) claims Review shop diagnostics, repair estimates, inspections, labor times, and parts pricing Determine coverage based on contract terms and service guidelines Authorize or deny repairs within settlement authority; escalate complex claims with recommendations Communicate professionally with customers, repair facilities, dealerships, agents, and inspectors Negotiate labor times, parts pricing, and scope of repairs when needed Ensure repairs and costs align with industry standards and contract limitations Accurately document claim decisions across multiple claims and estimating systems Identify and escalate gray-area or complex coverage issues Support service-level goals while delivering a positive customer and dealer experience Additional Responsibilities Participate in quality audits, peer reviews, and calibration sessions Assist with onboarding and training of new or junior adjusters Provide feedback on claim trends, cost drivers, and process improvements Support volume spikes, new program launches, or system migrations Collaborate with underwriting, compliance, product, and leadership teams on escalated claims Complete special projects and reporting as assigned What We're Looking For High school diploma or equivalent required; Bachelor's degree or equivalent experience preferred 2-4+ years of experience in automotive claims, VSC/extended warranty claims, warranty administration, or insurance adjusting Strong automotive background, including experience in: Automotive repair or diagnostics Dealership service roles (Service Advisor, Technician, Warranty Administrator) Fleet maintenance, parts management, or service writing Working knowledge of automotive diagnostics, repair procedures, labor times, and parts pricing Experience in a high-volume or call-based claims environment preferred Comfortable navigating multiple systems and platforms Preferred Qualifications ASE Certifications, factory training, or other automotive industry certifications Experience with Vehicle Service Contracts (VSCs), extended warranties, or TPAs Spanish / bilingual skills a plus Skills & Competencies Strong analytical and decision-making skills Excellent verbal and written communication Professional negotiation and conflict-resolution abilities High attention to detail and documentation accuracy Ability to interpret technical repair information and contract language Strong time management and schedule adherence Customer-focused mindset Ascendo is a certified minority owned staffing firm, and we welcome and celebrate diversity. Ascendo is an Equal Opportunity Employer and does not discriminate on the basis of race, color, religion, sex (including pregnancy and gender identity), national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, parental status, military service or any other characteristic protected by federal, state or local law
    $43k-52k yearly est. 2d ago
  • Disbursement Specialist

    Berlin Patten Ebling, PLLC 3.9company rating

    Sarasota, FL jobs

    Berlin Patten Ebling, PLLC is an award-winning Florida law firm known for excellence, collaboration, and innovation. With offices across the state, we provide sophisticated legal services without sacrificing culture or work-life balance. Job Duties: Monitor and process daily incoming/outgoing funds & wire transfers. Enter outgoing wires into the banking system and obtain required approvals Review closing files that have been authorized for disbursement and reconcile the disbursement ledger to the closing documents. Print checks and obtain necessary attorney signatures. Accurately disburse/mail out all proceeds payments. Various other duties as assigned. Requirements: A driven, self-motivated team player who thrives in a busy environment Excel in multi-tasking and prioritizing A quick learner who follows directions well. Great attention to detail and accuracy Dependable Benefits & Perks Competitive salary based on experience, plus bonus opportunities. Health insurance benefits Retirement plan options Paid time off and holidays CLE expenses covered. Annual all-expenses-paid firm trip (after eligibility period)
    $31k-57k yearly est. 5d ago
  • Day Hab Specialist (33275)

    Birch Family Services Inc. 3.9company rating

    New York, NY jobs

    To counsel, assist and train individuals with developmental disabilities in the areas of personal care, travel skills, social skills, home management and life skills in order to maximize their functioning in the community. Minimum Job Requirements: Educational: Minimum High School diploma or General Education Degree (GED). Experience: Minimum I-year experience working with developmentally disabled population preferably in a day hab, residential, health or treatment related setting preferred. Specialized Knowledge, Licenses, etc.: Specialized training in direct support provision preferred. Must complete and obtain certification in OPWDD Approved Medication Administration Course (AMAP) during probationary period and maintain AMAP certification. Valid NYS Driver's License required. Ability and willingness to be First Aid and CPR certified. Ability and willingness to obtain certification in SCIP-R Competencies and advance to Promote Competencies Demonstrated competency in written, verbal and computational skills to document records in accordance with program standards. Physical Demands: Regularly required to speak clearly and hear the spoken word well. Regularly required to utilize near vision ability to read data and documents, including spreadsheets and reports, in printed form and on computer screens. Ability to physically restrain challenging behaviors that include aggression, self-injurious, and destructive behaviors. Ability to use and navigate the public transportation system Ability to withstand excessive walking Work Environment: Noise level is consistent with levels usually present in an office, education, group home, residential, rehabilitation, industrial, workshop or health related environment. Hazards present are consistent with those common to an office, education, rehabilitation, industrial, workshop or health related environment. Working with individuals whose age ranges from 21 through adulthood Support individuals by providing opportunities to develop and enhance skills leading to independence, community inclusion and supported employments as appropriate. Examples include but are not limited to: Provide safe and clean environment for the individuals based on skill level and risks and support the safety of all individuals in everyday situations Use verbal and physical means to create a positive environment that will encourage and enable individual growth Using a holistic approach, participate in the individuals' day hab planning activities and assist in their implementation Assist the individuals in the development of social skills that will help them become integrated/included in the community Perform protective oversight while engaging in community activities Support individuals to engage in meaningful activities and assist in employment opportunities Provide opportunities for the individual to be self-advocate Perform advocate responsibilities, while demonshating respect for the processes and people involved Responsible for all documentation related to the essential function and services for the individual Adhere to the procedures for mandated reporting and responding Adhere to the NADSP code of ethics (attached) Work towards the satisfactory completion of each of the core competency goals according to the OPWDD timeline requirements Other Functions: Demonstrate respect for all people Demonstrate professional demeanor, attention to punctuality and attendance policies, reliability, flexibility, and pleasantness. Professionally interact with other staff members and with others in the community Demonstrate enthusiasm for learning the knowledge and skills required to perform the job Readily seek and accept feedback to improve performance Apply knowledge and skills gained on the job and maintain required certifications Participate in the work of the organization in a positive way by using problem solving skills Demonstrate respect for the safety of all others Perform additional responsibilities as assigned by the Senior Staff May be assigned other tasks and duties reasonably related to their job responsibilities Adhere to all rules outlined in the policy and procedures manual The position description is a guide to the critical duties and essential functions of the job, not an all-inclusive list of responsibilities, qualifications, physical demands and work environment conditions. Position descriptions are reviewed and revised to meet the changing needs of the agency at the sole discretion of management. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions unless this causes undue hardship to the company. Performance is evaluated each year based on these competencies and the NADSP code of ethics.
    $35k-47k yearly est. 1d ago
  • Lockbox Specialist

    Appleone 4.3company rating

    Lewisville, TX jobs

    Job Description: Role reports to a lockbox (vault). This is a long-term role within the Receivable Operations. Production line type of environment inside a secured vault. Detailed information cannot be provided until candidate is cleared by the client: • Preparing work for digitation by extracting payments and documents from mailing envelopes • Inputting and validating data into the system • Operating high-volume document scanning machines while validating the quality of scanned images • Validating/reconciling electronic reports to paper documentation • Making judgement calls regarding routine duties while referring non-routine situations to a manager • Willingness to learn new processing functions and equipment operations is needed • Maintaining site productivity, quality, accuracy and confidentiality standards while meeting well defined goals • Ensuring that all customer and bank guidelines are followed as it relates to operations, internal audit, security and general practices Requirements: • At least 7 years of USA residence history • Proof of US Citizenship - us birth certificate, passport, permanent resident card, certificate of US citizenship or Naturalization • State Issued form of ID (ID/Driver's license) MUST BE VALID and not expired • Data Entry skills • Ability to pass in-depth background check and credit worthiness • Willing to work in a high security production environment while adhering to strict regulations including no cell phones/smart watches on production floor • Ability to sit, stand, walk and lift up to 50 lbs • No time off in first 90 days Shifts Available/Pay Rates: 2nd Shift: M-F 3:30 pm-12 am ($22/hr) Weekend: Fri - Mon 7am-5:30pm ($22/hr) Equal Opportunity Employer / Disabled / Protected Veterans The Know Your Rights poster is available here: *********************************************************************************** The pay transparency policy is available here: ******************************************************************************************** For temporary assignments lasting 13 weeks or longer, AppleOne is pleased to offer major medical, dental, vision, 401k and any statutory sick pay where required. We are committed to working with and providing reasonable accommodations to individuals with disabilities. If you need a reasonable accommodation for any part of the employment process, please contact your staffing representative who will reach out to our HR team. AppleOne participates in the E-Verify program in certain locations as required by law. Learn more about the E-Verify program. ********************************************** Contents/E-Verify_Participation_Poster_ES.pdf We also consider for employment qualified applicants regardless of criminal histories, consistent with legal requirements, including, if applicable, the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance. Pursuant to applicable state and municipal Fair Chance Laws and Ordinances, we will consider for employment-qualified applicants with arrest and conviction records, including, if applicable, the San Francisco Fair Chance Ordinance. For Los Angeles, CA applicants: Qualified applications with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.
    $22 hourly 3d ago
  • Maximo Specialist

    Brooksource 4.1company rating

    Fort Worth, TX jobs

    Our Federal Systems integrator is seeking an experienced Maximo Specialist to support a aviation asset management program with a government partner. This role supports a highly regulated, mission-critical environment and requires a consistent on-site presence in Fort Worth, TX. The Maximo Specialist will serve as a key on-site resource responsible for coordinating delivery activities, supporting system operations, and acting as a liaison between business stakeholders and technical delivery teams. This individual will play a critical role in ensuring the stability, enhancement, and effective use of IBM Maximo in support of aviation operations. Key Responsibilities Serve as the primary on-site Maximo subject matter resource for day-to-day operations Coordinate delivery activities related to IBM Maximo enhancements, sustainment, and operational support Work closely with functional consultants, developers, and stakeholders to support Maximo workflows Translate operational requirements into actionable tasks and priorities for delivery teams Manage timelines, dependencies, and risks across Maximo-related workstreams Facilitate on-site meetings, status updates, and stakeholder communication Support documentation, reporting, and compliance requirements in a regulated environment Ensure system reliability and alignment with operational and regulatory needs Required Qualifications Hands-on experience working with IBM Maximo in a delivery or operational capacity Strong understanding of enterprise asset management (EAM) systems and processes Experience supporting complex or regulated environments Ability and willingness to work on-site full-time in Fort Worth, TX Strong communication and stakeholder coordination skills Preferred Qualifications Experience supporting aviation, transportation, defense, or government programs Familiarity with Maximo modules such as Asset Management, Work Management, or Preventive Maintenance Experience supporting long-term operational or sustainment-based programs Experience working in client-facing or consulting environments Why This Role Long-term, stable aviation program with strong stakeholder engagement High-impact, on-site role supporting mission-critical operations Opportunity to serve as a trusted Maximo expert within a complex delivery environment
    $56k-106k yearly est. 2d ago
  • HRIS Specialist, Paycom

    Wheeler Staffing Partners 4.4company rating

    Plano, TX jobs

    Employment Type: Direct Hire Schedule: Hybrid - 3 days onsite per week Salary: $50,000 - $60,000 annually Wheeler Staffing Partners is seeking a detail-oriented HRIS Specialist / HRIS Administrator for a direct hire opportunity in Plano, Texas. This role supports HR technology operations with a strong emphasis on Paycom administration, data integrity, reporting, and system optimization. The ideal candidate brings strong analytical skills, advanced Excel proficiency, and recent hands-on experience managing HRIS functions in a fast-paced environment. Key Responsibilities HRIS Administration Serve as the primary administrator for Paycom, including configuration, workflow management, and module maintenance. Support system updates, feature rollouts, and enhancements. Perform routine data audits and clean-up to maintain accuracy and compliance. Troubleshoot HRIS issues and coordinate with Paycom support when necessary. Consolidate employee data from an acquired company into existing systems (ADP / Paycom), ensuring accuracy and completeness. Data Integrity & Maintenance Review employee files and verify data accuracy across systems. Resolve data discrepancies such as duplicates, missing fields, and formatting inconsistencies. Pull and update timecards as required. Reporting & Analytics Create, extract, and maintain HR reports and dashboards. Build custom reports within Paycom to support HR, payroll, benefits, and compliance initiatives. Provide accurate data and reporting to support decision-making for HR leadership. Process Improvement Evaluate HR workflows and identify opportunities to streamline or automate processes in Paycom. Document standard operating procedures (SOPs) and recommend system and process enhancements. User Support & Training Provide HRIS support to HR staff, managers, and employees. Lead Paycom training for onboarding, performance, benefits enrollment, and timekeeping. Maintain user guides, training materials, and reference documentation. Compliance Maintain data accuracy and ensure system compliance with federal and state regulations. Support audits related to payroll, benefits, timekeeping, and other HR functions. Required Qualifications 2+ years of HRIS experience, including 1+ year of hands-on Paycom administration. Strong understanding of HR functions such as payroll, onboarding, benefits, performance, and compliance. Advanced Excel skills (pivot tables, VLOOKUP/XLOOKUP). Experience consolidating and validating employee data across multiple systems preferred. Excellent attention to detail, problem-solving ability, and communication skills. Why Work With Wheeler Staffing Partners? Wheeler Staffing Partners is committed to connecting top talent with meaningful career opportunities by providing personalized guidance, transparent communication, and dedicated support throughout every step of the hiring process. Our recruiting team works closely with candidates to match them with roles that align with their experience, goals, and long-term aspirations. We take pride in partnering with reputable clients and offering opportunities that foster growth, stability, and professional development, ensuring a smooth and positive experience from application to placement.
    $50k-60k yearly 4d ago
  • Onboarding Specialist

    Aerotek 4.4company rating

    Omaha, NE jobs

    Why Aerotek? Aerotek is an operating company within Allegis Group, a global leader in talent solutions. We are a privately held organization with over 200+ offices nationwide. We work with 95% of Fortune 500 companies and specialize in staffing and services solutions in manufacturing, logistics, construction, aviation, facilities and maintenance. Working at Aerotek and why you will love it… At Aerotek, we prioritize inclusivity and foster a magnetic work environment that empowers our employees to achieve both personal and professional aspirations. By putting the people first, our corporate culture encourages employee engagement and enhances performance through comprehensive training and a positive culture. We promote exclusively from within. You will… Ensure client pre-employment requirements, forms, policies, and documents regarding onboarding are kept current and validated with Compliance departments. Manage client requirements for the onboarding packet (e.g., authorization forms, drug tests, background checks etc.) and update the Candidate Tracker with contractor data until candidate is cleared to start. Enter and manage background, drug testing and medical screening process for contractors. Manage contractor compliance with key E-Verify requirements (e.g., expired documents, expired compliance). Provide outstanding front office customer service (telephone and reception area) Order, maintain and organize all office supplies, manage mailing and shipments, and file and maintain office paperwork and office directory. Provide world class customer service in every interaction to ensure a quality candidate experience. Let's talk money and perks! Aerotek offers an hourly rate of $20.19 as well as a performance-based annual bonus potential of $4,000. Additional benefits include: Medical, dental and vision HSA & 401k account 20 days of paid time off as well as paid holidays Parental/Family leave Employee discounts Employee-led resource groups Do you have the following? Bachelor's Degree (preferred) Customer or sales focused experience Experience in a team-oriented environment
    $20.2 hourly 3d ago
  • Claims Manager - Professional Liability

    Counterpart International 4.3company rating

    Remote

    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.
    $150k-180k yearly Auto-Apply 60d+ ago
  • Claims Specialist

    Creative Financial Staffing 4.6company rating

    Reynoldsburg, OH jobs

    Our client in the medical supply industry is seeking a Claims Specialist to support a high-impact revenue recovery project tied to recent Medicare and Tricare processing changes. Salary is $41,600-$52,000, DOE ABOUT OUR CLIENT A well-established provider of medical equipment in the Columbus-area Known for supporting both private and government healthcare networks Collaborative, detail-driven office culture focused on accuracy and results Casual work environment with an emphasis on professional accountability Opportunity to make a measurable impact on recovering aged receivables and strengthening cash flow as the Claims Specialist RESPONSIBILITIES OF THE CLAIMS SPECIALIST The Claims Specialist will post claims in Bonafide, ensuring all data meets current HCPC and Tricare standards The Claims Specialist will reconcile and correct rejected or pending claims, attaching required documentation and resubmitting for processing Communicate directly with Medicare and Tricare representatives to verify claim receipt, payment status, and issue resolution Track, document, and report claim and cash recovery progress to leadership PREFERRED QUALIFICATIONS FOR THE CLAIMS SPECIALIST Must have hands-on experience with both Tricare and Medicare billing Must have direct experience using Bonafide billing software Knowledge of claims processing, EOB reconciliation, and appeals workflow Experience with Excel is a plus (basic to intermediate proficiency) Salary is $41,600-$52,000, DOE
    $41.6k-52k yearly 1d ago
  • Claims Review Specialist-25448

    Knowledge Builders 3.6company rating

    Washington jobs

    Job Description Mission statement of OHIP: The overall mission of the Office of Health Insurance Programs is to optimize the health of Medicaid members by wisely using all available resources. OHIP is responsible for administering New York's Medicaid budget (approximately $65B for 2018) by collaborating with stakeholders across the health care industry including other state agencies, local and federal government agencies, providers, members, and community-based organizations. OHIP is also responsible for implementation of major initiatives including Medicaid Redesign, the Affordable Care Act, and State Administration of Medicaid. Division functions: The Division of Medical and Dental Directors (DMDD) is responsible to support and further strengthen the ability to coordinate medical and dental policy direction across all aspects of Medicaid, including managed care, fee-for-service, and waiver programs. The DMDD Bureau of Medical Review performs Medicaid operational functions including prior authorization for durable medical equipment, medical supplies, private duty nursing services, hearing aids, and out-of-state hospital and skilled nursing facility admissions. The bureau is also responsible for the review and adjudication of Medicaid claims that pend for pricing, medical review, timeliness of submissions, and adherence to Medicaid claim submission policies. Additionally, the bureau operates a call center to answer inquiries from providers and members regarding prior approval policy and status. Position Description: These positions are located within DMDD, Bureau of Medical Review, Durable Medical Equipment, Medical Supplies Prior Approval units. These positions have multiple responsibilities including, but not limited to: • Providing clerical and administrative support to the Prior Approval Units, including the preparation, organization, and assembly of Fair Hearing packets that need to be mailed to members, representatives and providers. • Reviewing Fair Hearing packets for completeness and inclusion of all required documentation prior to distribution. • Scanning and uploading all Fair Hearing documents for processing. • Processing packages for mailing within required timeframes. • Performing medical claims pricing for medical pended claims. • Reviewing invoices, applying established pricing methodologies, and performing accurate calculations in accordance with Medicaid reimbursement rules. • Entering pricing determinations and related data into the eMedNY system with high degree of accuracy and attention to detail. • Identifying discrepancies, missing documentation, or potential billing issues and escalating appropriately. • Conducting initial and basic reviews of requests for durable medical equipment and medical supplies using established criteria. • Escalating cases that fall outside of standard criteria to clinical staff (therapists, nurses, or other designated professionals) for further review and determination. • Responding to basic inquiries from providers and members via phone and email regarding prior approval status, documentation requirements, and general policy guidance in a clear, professional and courteous manner. • Adhering to established workflows, turnaround times, and performance standards to support bureau-wide service level goals. Additional Skill Level, Experience or Other Requirements: • High School Diploma or equivalent required • Experience with Microsoft Word and Excel • Proficient in the use of standard office technology • Basic knowledge of medical terminology • Ability to be flexible, innovative, and work in a team environment • Strong written and verbal communication skills • Previous claims experience preferred but not required
    $56k-74k yearly est. 7d ago
  • Claims Specialist

    Mindlance 4.6company rating

    Lake Mary, FL jobs

    My name is Pondsy Anthony , and I am Recruiting Specialist with Mindlance Inc . I have reviewed your resume and at a first glance find it to be a good fit for a Position that we are exclusively recruiting for. We are working very closely with our Client based in FL to fill this requirement urgently. This is a 4+ months of contract position with a possible extension depending on performance. You can get back to me at ************ to discuss in detail. Job Description Job Title: Claim Specialist Client Location : 255 Technology Park, Lake Mary, FL 32746 Contract Duration : 4+ months (High possibility of Extension) ***Info about Schedules: - Candidates being selected need to be open for the contractor shift of either 9a-6p or 10a-7p or 11-8. - If contractors are hired on, they have to be available for shifts like 11a-8p and 12p-9p. Please let candidates know this! Looking for :- Candidates must have reimbursement experience that is within the past 6 months Prior authorization - submission, review, support, completion, verification Appeal - submission, review, support, completion, verification, coordination Reimbursement - investigation, verification JOB SUMMARY: The primary function/purpose of this job:- Verify member submitted claims forms, member's eligibility and pharmacy information is complete and accurate, updating system information as needed. Superior data entry proficiency is expected in order to provide accurate and timely processing of claims submitted by member, pharmacy or appropriate agency. Moderate knowledge of drugs and drug terminology used daily. Process claims according to client specific guidelines while identifying claims requiring exception handling. Navigate daily through several platforms to research and accurately finalize claim submissions. Oral or written communication with internal departments, members, pharmacies or agencies to resolve claim issues. Adhere to strict HIPAA regulations especially when communicating to others outside of Express Scripts. Prioritize and coordinate influx of daily workload for claims processing, returned mail and out-going correspondence and e-mails to assure required turnaround time is met. Assess accuracy of system adjudication and alert management of potential problems affecting the integrity of claim processing. Analyze claims for potential fraud by member or pharmacy. May be required to work on special projects for claims team. SCOPE OF JOB Reimbursement verification of enrollments MINIMUM QUALIFICATIONS TO ENTER THE JOB: Formal Education and/or Training: High school diploma or equivalent required, some college or technical training preferred YEARS OF EXPERIENCE: Two years' experience in P.B.M. environment is helpful but not required. KNOWLEDGE AND ABILITIES: • Strong data entry and 10-key skills • Retail pharmacy, customer service experience helpful but not required • PC and MS Office literate • Strong attention to detail • Excellent retention and judgment ability • Proficient written and oral communication skills • Ability to work in fast-paced, production environment • Reliable, self-motivated with excellent attendance • Team player who has the ability to stay on task with little supervision Qualifications • Prior authorization - submission, review, support, completion, verification • Appeal - submission, review, support, completion, verification, coordination • Reimbursement - investigation, verification Additional Information All your information will be kept confidential according to EEO guidelines.
    $37k-51k yearly est. 6h ago
  • Claims Specialist

    Mindlance 4.6company rating

    Lake Mary, FL jobs

    My name is Pondsy Anthony, and I am Recruiting Specialist with Mindlance Inc. I have reviewed your resume and at a first glance find it to be a good fit for a Position that we are exclusively recruiting for. We are working very closely with our Client based in FL to fill this requirement urgently. This is a 4+ months of contract position with a possible extension depending on performance. You can get back to me at ************ to discuss in detail. Job Description Job Title: Claim Specialist Client Location : 255 Technology Park, Lake Mary, FL 32746 Contract Duration : 4+ months (High possibility of Extension) ***Info about Schedules: - Candidates being selected need to be open for the contractor shift of either 9a-6p or 10a-7p or 11-8. - If contractors are hired on, they have to be available for shifts like 11a-8p and 12p-9p. Please let candidates know this! Looking for :- Candidates must have reimbursement experience that is within the past 6 months Prior authorization - submission, review, support, completion, verification Appeal - submission, review, support, completion, verification, coordination Reimbursement - investigation, verification JOB SUMMARY: The primary function/purpose of this job:- Verify member submitted claims forms, member's eligibility and pharmacy information is complete and accurate, updating system information as needed. Superior data entry proficiency is expected in order to provide accurate and timely processing of claims submitted by member, pharmacy or appropriate agency. Moderate knowledge of drugs and drug terminology used daily. Process claims according to client specific guidelines while identifying claims requiring exception handling. Navigate daily through several platforms to research and accurately finalize claim submissions. Oral or written communication with internal departments, members, pharmacies or agencies to resolve claim issues. Adhere to strict HIPAA regulations especially when communicating to others outside of Express Scripts. Prioritize and coordinate influx of daily workload for claims processing, returned mail and out-going correspondence and e-mails to assure required turnaround time is met. Assess accuracy of system adjudication and alert management of potential problems affecting the integrity of claim processing. Analyze claims for potential fraud by member or pharmacy. May be required to work on special projects for claims team. SCOPE OF JOB Reimbursement verification of enrollments MINIMUM QUALIFICATIONS TO ENTER THE JOB: Formal Education and/or Training: High school diploma or equivalent required, some college or technical training preferred YEARS OF EXPERIENCE: Two years' experience in P.B.M. environment is helpful but not required. KNOWLEDGE AND ABILITIES: • Strong data entry and 10-key skills • Retail pharmacy, customer service experience helpful but not required • PC and MS Office literate • Strong attention to detail • Excellent retention and judgment ability • Proficient written and oral communication skills • Ability to work in fast-paced, production environment • Reliable, self-motivated with excellent attendance • Team player who has the ability to stay on task with little supervision Qualifications • Prior authorization - submission, review, support, completion, verification • Appeal - submission, review, support, completion, verification, coordination • Reimbursement - investigation, verification Additional Information All your information will be kept confidential according to EEO guidelines.
    $37k-51k yearly est. 60d+ ago
  • Claim Specialist

    Mindlance 4.6company rating

    Lake Mary, FL jobs

    Mindlance is a national recruiting company which partners with many of the leading employers across the country. Feel free to check us out at ************************* Job Description Business Claim Specialist Visa GC/Citizen Location 255 Technology Park, Lake Mary FL 32746 Division Pharmaceutical Pay $16.00/hr. Contract 5 Month Timings Mon - Fri between 9.00AM - 6.00PM POSITION OVERVIEW The primary function/purpose of this job. Verify member submitted claims forms, member's eligibility and pharmacy information is complete and accurate, updating system information as needed. Superior data entry proficiency is expected in order to provide accurate and timely processing of claims submitted by member, pharmacy or appropriate agency. Moderate knowledge of drugs and drug terminology used daily. Process claims according to client specific guidelines while identifying claims requiring exception handling. Navigate daily through several platforms to research and accurately finalize claim submissions. Oral or written communication with internal departments, members, pharmacies or agencies to resolve claim issues. Adhere to strict HIPAA regulations especially when communicating to others outside the client. Prioritize and coordinate influx of daily workload for claims processing, returned mail and out-going correspondence and e-mails to assure required turnaround time is met. Assess accuracy of system adjudication and alert management of potential problems affecting the integrity of claim processing. Analyze claims for potential fraud by member or pharmacy. May be required to work on special projects for claims team. ESSENTIAL FUNCTIONS: The 6-10 major responsibility areas of the job. Weight: (%) (Total = 100%) 1. Manage member and client expectations related to claim reimbursements. Input claim requests into adjudication platform maintaining compliance to performance guarantees, HIPAA guidelines and service standards, which include production and accuracy standards. Processing according to client guidelines making exceptions upon member appeal and client approval. Recognize and escalate appropriate system crises/problems and fraudulent claims to management. 40 % 2. Identify claims requiring additional research, navigate through appropriate system platforms to perform research and resolve issue or forward as appropriate 15 % 3. Research to define values for missing information not submitted with claim but required for processing. Identify drug form, type and strength to manually determine correct NDC number value which will allow claim to process. Continue researching values if system editing does not accept original assigned value. Utilize anchor platform, internet resources and/or contacting retail pharmacist as resources for missing values. 15 % 4. Initiate correspondence to members, pharmacies or other internal departments for missing information, claim denials or other claim issues. 15 % 5. Evaluate claim submission, ensure all required information is present and determine what action should be taken. Confirm patient eligibility and verify patient information matches system. Update member's address to match claim form if necessary. 5 % 6. Identify exception handling and process per client requirements. Monitor system to ensure client specific documentation related to claims processing and benefits is current and system editing is operating appropriately. 5 % 7. Variety of other miscellaneous duties as assigned 5 % SCOPE OF JOB Provide quantitative data reflecting the scope and impact of the job - such as budget managed, sales/revenues, profit, clients served, adjusted scripts, etc. Maintain an average of 30 Commercial claims per hour (cph) or 35 Work Comp claims per hour (cph). Qualifications Formal Education and/or Training: High school diploma or equivalent required, some college or technical training preferred Years of Experience: Two years' experience in P.B.M. environment is helpful but not required. Computer or Other Skills: Strong data entry, 10-key skills, general PC skills and MS Office experience Knowledge and Abilities: • Strong data entry and 10-key skills • Retail pharmacy, customer service experience helpful but not required • PC and MS Office literate • Strong attention to detail • Excellent retention and judgment ability • Proficient written and oral communication skills • Ability to work in fast-paced, production environment • Reliable, self-motivated with excellent attendance • Team player who has the ability to stay on task with little supervision Additional Information Thanks & Regards, Ranadheer Murari | Recruitment Executive | Mindlance, Inc. | W: ************ ***************************
    $16 hourly Easy Apply 60d+ ago
  • Claim Specialist

    Mindlance 4.6company rating

    Lake Mary, FL jobs

    Business Claim Specialist Visa GC/Citizen Division Pharmaceutical Pay $16.00/hr. Contract 5 Month Timings Mon - Fri between 9.00AM - 6.00PM The primary function/purpose of this job. Verify member submitted claims forms, member's eligibility and pharmacy information is complete and accurate, updating system information as needed. Superior data entry proficiency is expected in order to provide accurate and timely processing of claims submitted by member, pharmacy or appropriate agency. Moderate knowledge of drugs and drug terminology used daily. Process claims according to client specific guidelines while identifying claims requiring exception handling. Navigate daily through several platforms to research and accurately finalize claim submissions. Oral or written communication with internal departments, members, pharmacies or agencies to resolve claim issues. Adhere to strict HIPAA regulations especially when communicating to others outside the client. Prioritize and coordinate influx of daily workload for claims processing, returned mail and out-going correspondence and e-mails to assure required turnaround time is met. Assess accuracy of system adjudication and alert management of potential problems affecting the integrity of claim processing. Analyze claims for potential fraud by member or pharmacy. May be required to work on special projects for claims team. ESSENTIAL FUNCTIONS: The 6-10 major responsibility areas of the job. Weight: (%) (Total = 100%) 1. Manage member and client expectations related to claim reimbursements. Input claim requests into adjudication platform maintaining compliance to performance guarantees, HIPAA guidelines and service standards, which include production and accuracy standards. Processing according to client guidelines making exceptions upon member appeal and client approval. Recognize and escalate appropriate system crises/problems and fraudulent claims to management. 40 % 2. Identify claims requiring additional research, navigate through appropriate system platforms to perform research and resolve issue or forward as appropriate 15 % 3. Research to define values for missing information not submitted with claim but required for processing. Identify drug form, type and strength to manually determine correct NDC number value which will allow claim to process. Continue researching values if system editing does not accept original assigned value. Utilize anchor platform, internet resources and/or contacting retail pharmacist as resources for missing values. 15 % 4. Initiate correspondence to members, pharmacies or other internal departments for missing information, claim denials or other claim issues. 15 % 5. Evaluate claim submission, ensure all required information is present and determine what action should be taken. Confirm patient eligibility and verify patient information matches system. Update member's address to match claim form if necessary. 5 % 6. Identify exception handling and process per client requirements. Monitor system to ensure client specific documentation related to claims processing and benefits is current and system editing is operating appropriately. 5 % 7. Variety of other miscellaneous duties as assigned 5 % SCOPE OF JOB Provide quantitative data reflecting the scope and impact of the job - such as budget managed, sales/revenues, profit, clients served, adjusted scripts, etc. Maintain an average of 30 Commercial claims per hour (cph) or 35 Work Comp claims per hour (cph). Qualifications Formal Education and/or Training: High school diploma or equivalent required, some college or technical training preferred Years of Experience: Two years' experience in P.B.M. environment is helpful but not required. Computer or Other Skills: Strong data entry, 10-key skills, general PC skills and MS Office experience Knowledge and Abilities: • Strong data entry and 10-key skills • Retail pharmacy, customer service experience helpful but not required • PC and MS Office literate • Strong attention to detail • Excellent retention and judgment ability • Proficient written and oral communication skills • Ability to work in fast-paced, production environment • Reliable, self-motivated with excellent attendance • Team player who has the ability to stay on task with little supervision Additional Information Thanks & Regards, Ranadheer Murari | Recruitment Executive | Mindlance, Inc. | W : ************ ***************************
    $16 hourly Easy Apply 6h ago
  • Claim Specialist // Memphis TN 38134

    Mindlance 4.6company rating

    Memphis, TN jobs

    Mindlance is a national recruiting company which partners with many of the leading employers across the country. Feel free to check us out at ************************* Job Description Business Claim Specialist Visa GC/Citizen Location 1680 Century Center Parkway, Memphis TN 38134 Division Pharmaceutical Contract 6 Month Timings Mon - Fri between 8.00AM - 5.00PM Qualifications POSITION OVERVIEW The primary function/purpose of this job. Verify member submitted claims forms, member's eligibility and pharmacy information is complete and accurate, updating system information as needed. Superior data entry proficiency is expected in order to provide accurate and timely processing of claims submitted by member, pharmacy or appropriate agency. Moderate knowledge of drugs and drug terminology used daily. Process claims according to client specific guidelines while identifying claims requiring exception handling. Navigate daily through several platforms to research and accurately finalize claim submissions. Oral or written communication with internal departments, members, pharmacies or agencies to resolve claim issues. Adhere to strict HIPAA regulations especially when communicating to others outside the client. Prioritize and coordinate influx of daily workload for claims processing, returned mail and out-going correspondence and e-mails to assure required turnaround time is met. Assess accuracy of system adjudication and alert management of potential problems affecting the integrity of claim processing. Analyze claims for potential fraud by member or pharmacy. May be required to work on special projects for claims team. ESSENTIAL FUNCTIONS: The 6-10 major responsibility areas of the job. Weight: (%) (Total = 100%) 1. Manage member and client expectations related to claim reimbursements. Input claim requests into adjudication platform maintaining compliance to performance guarantees, HIPAA guidelines and service standards, which include production and accuracy standards. Processing according to client guidelines making exceptions upon member appeal and client approval. Recognize and escalate appropriate system crises/problems and fraudulent claims to management. 40 % 2. Identify claims requiring additional research, navigate through appropriate system platforms to perform research and resolve issue or forward as appropriate 15 % 3. Research to define values for missing information not submitted with claim but required for processing. Identify drug form, type and strength to manually determine correct NDC number value which will allow claim to process. Continue researching values if system editing does not accept original assigned value. Utilize anchor platform, internet resources and/or contacting retail pharmacist as resources for missing values. 15 % 4. Initiate correspondence to members, pharmacies or other internal departments for missing information, claim denials or other claim issues. 15 % 5. Evaluate claim submission, ensure all required information is present and determine what action should be taken. Confirm patient eligibility and verify patient information matches system. Update member's address to match claim form if necessary. 5 % 6. Identify exception handling and process per client requirements. Monitor system to ensure client specific documentation related to claims processing and benefits is current and system editing is operating appropriately. 5 % 7. Variety of other miscellaneous duties as assigned 5 % SCOPE OF JOB Provide quantitative data reflecting the scope and impact of the job - such as budget managed, sales/revenues, profit, clients served, adjusted scripts, etc. Maintain an average of 30 Commercial claims per hour (cph) or 35 Work Comp claims per hour (cph). MINIMUM QUALIFICATIONS TO ENTER THE JOB: Formal Education and/or Training: High school diploma or equivalent required, some college or technical training preferred Years of Experience: Two years' experience in P.B.M. environment is helpful but not required. Computer or Other Skills: Strong data entry, 10-key skills, general PC skills and MS Office experience Knowledge and Abilities: • Strong data entry and 10-key skills • Retail pharmacy, customer service experience helpful but not required • PC and MS Office literate • Strong attention to detail • Excellent retention and judgment ability • Proficient written and oral communication skills • Ability to work in fast-paced, production environment • Reliable, self-motivated with excellent attendance • Team player who has the ability to stay on task with little supervision If you are available and interested then please reply me with your “Chronological Resume” and call me on **************. Additional Information Thanks & Regards, Ranadheer Murari | Team Recruitment | Mindlance, Inc. | W: ************ *************************
    $29k-38k yearly est. Easy Apply 60d+ ago
  • Claim Specialist // Memphis TN 38134

    Mindlance 4.6company rating

    Memphis, TN jobs

    Business Claim Specialist Visa GC/Citizen Division Pharmaceutical Contract 6 Month Timings Mon - Fri between 8.00AM - 5.00PM Qualifications The primary function/purpose of this job. Verify member submitted claims forms, member's eligibility and pharmacy information is complete and accurate, updating system information as needed. Superior data entry proficiency is expected in order to provide accurate and timely processing of claims submitted by member, pharmacy or appropriate agency. Moderate knowledge of drugs and drug terminology used daily. Process claims according to client specific guidelines while identifying claims requiring exception handling. Navigate daily through several platforms to research and accurately finalize claim submissions. Oral or written communication with internal departments, members, pharmacies or agencies to resolve claim issues. Adhere to strict HIPAA regulations especially when communicating to others outside the client. Prioritize and coordinate influx of daily workload for claims processing, returned mail and out-going correspondence and e-mails to assure required turnaround time is met. Assess accuracy of system adjudication and alert management of potential problems affecting the integrity of claim processing. Analyze claims for potential fraud by member or pharmacy. May be required to work on special projects for claims team. ESSENTIAL FUNCTIONS: The 6-10 major responsibility areas of the job. Weight: (%) (Total = 100%) 1. Manage member and client expectations related to claim reimbursements. Input claim requests into adjudication platform maintaining compliance to performance guarantees, HIPAA guidelines and service standards, which include production and accuracy standards. Processing according to client guidelines making exceptions upon member appeal and client approval. Recognize and escalate appropriate system crises/problems and fraudulent claims to management. 40 % 2. Identify claims requiring additional research, navigate through appropriate system platforms to perform research and resolve issue or forward as appropriate 15 % 3. Research to define values for missing information not submitted with claim but required for processing. Identify drug form, type and strength to manually determine correct NDC number value which will allow claim to process. Continue researching values if system editing does not accept original assigned value. Utilize anchor platform, internet resources and/or contacting retail pharmacist as resources for missing values. 15 % 4. Initiate correspondence to members, pharmacies or other internal departments for missing information, claim denials or other claim issues. 15 % 5. Evaluate claim submission, ensure all required information is present and determine what action should be taken. Confirm patient eligibility and verify patient information matches system. Update member's address to match claim form if necessary. 5 % 6. Identify exception handling and process per client requirements. Monitor system to ensure client specific documentation related to claims processing and benefits is current and system editing is operating appropriately. 5 % 7. Variety of other miscellaneous duties as assigned 5 % SCOPE OF JOB Provide quantitative data reflecting the scope and impact of the job - such as budget managed, sales/revenues, profit, clients served, adjusted scripts, etc. Maintain an average of 30 Commercial claims per hour (cph) or 35 Work Comp claims per hour (cph). MINIMUM QUALIFICATIONS TO ENTER THE JOB: Formal Education and/or Training: High school diploma or equivalent required, some college or technical training preferred Years of Experience: Two years' experience in P.B.M. environment is helpful but not required. Computer or Other Skills: Strong data entry, 10-key skills, general PC skills and MS Office experience Knowledge and Abilities: • Strong data entry and 10-key skills • Retail pharmacy, customer service experience helpful but not required • PC and MS Office literate • Strong attention to detail • Excellent retention and judgment ability • Proficient written and oral communication skills • Ability to work in fast-paced, production environment • Reliable, self-motivated with excellent attendance • Team player who has the ability to stay on task with little supervision If you are available and interested then please reply me with your “ Chronological Resume” and call me on ************** . Additional Information Thanks & Regards, Ranadheer Murari | Team Recruitment | Mindlance, Inc. | W : ************ *************************
    $29k-38k yearly est. Easy Apply 6h ago

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