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claims analyst

EmblemHealth

<div></div><div><div>Summary of Position</div><ul><li>
Support contract performance management of a large health system.<br>
</li><li>
Review and analyze suspected underpaid and overpaid claims from hospital, ancillary, and provider groups based on contractual and industry guidelines.<br>
</li><li>
Identify and analyze single issues and trends to determine root causes.<br>
</li><li>
Provide recommendations for solutions to minimize errors and delays in systems and/or processes.<br>
</li><li>
Monitor system output to ensure proper functioning.</li></ul><div><br>
Principal Accountabilities</div><ul><li>
Evaluate disputed claims for system configuration, claims processing, and/or contractual issues to facilitate claims review.<br>
</li><li>
Maintain and organize detailed information on claims dispute files to ensure appropriate and comprehensive data is returned to the provider timely.<br>
</li><li>
Track issues and monitor trends to support their resolution.<br>
</li><li>
Identify potential/actual claims problems (single or recurring/trending) and document root cause analysis; present findings to management.<br>
</li><li>
Improve quality, enhance workflow, and provide efficiencies within departments, identify opportunities for improvements; develop and present recommendations for changes.<br>
</li><li>
Conduct regular meetings with the assigned provider groups for status of AR files and recycles<br>
</li><li>
Support departmental goals for cycle time by organizing and tracking claims for review.<br>
</li><li>
Monitor and provide timely responses for the designated provider group emails and AR files.<br>
</li><li>
Perform other related tasks as directed or required.</li></ul><br>
<div></div><div><div>Qualifications</div><div>
Education, Training, Licenses, Certifications</div><ul><li>
Bachelor&rsquo;s Degree.</li></ul><div><br>
Relevant Work Experience, Knowledge, Skills, and Abilities</div><ul><li>
2 &ndash; 3 years&rsquo; prior related work experience in professional/facility claims or benefits/billing environment.<br>
</li><li>
Additional experience/specialized training may be considered in lieu of educational requirements.<br>
</li><li>
Strong knowledge of claim processing policies and procedures.<br>
</li><li>
Knowledge of medical terminology, ICD/CPT coding, per diem and DRG reimbursement and EDP testing procedures.<br>
</li><li>
Proficiency with MS Office applications (word processing, database/spreadsheet, presentation).<br>
</li><li>
Ability to accurately interpret information from contractual and technical perspectives.<br>
</li><li>
Must be conscientious and detail oriented; ability to recognize unusual patterns and troubleshoot for operational improvement and efficiencies.<br>
</li><li>
Strong analytical and problem-solving skills.<br>
</li><li>
Ability to effectively work on multiple projects/tasks with competing priority levels and deadlines.<br>
</li><li>
Ability to effectively absorb and communicate information.<br>
</li><li>
Strong Interpersonal and teamwork skills.</li></ul>
</div><div><p>Additional Information
</p><ul><li>Requisition ID: 1000002984</li>
<li>Hiring Range: $48,600-$83,160</li></ul></div></div>

Claims Review Analyst

VNS Health

<div><b>Overview</b><br>
<br>
Compiles, analyzes, and interprets overpayments through quarterly trend reporting for cost avoidance and recovery initiatives. Co-ordinate with business to align with payment recoveries disseminating findings for affordability initiatives. Conducts analysis of claims and payment data across health plans in support of ensuring payment integrity and cost containment. Identifies anomalous utilization patterns, investigates cost containment, and tests alignment with vendor's contracted rates. Reconciles and validates underlying analytic data claims, and utilization management systems. Tests the integrity of utilization and payment data across plans and functions. Engages in activities to support corrective actions to functions, Operations and Compliance as directed. Works under general supervision<br>
<br>
<br>
<br>
<br>
<p><b>What We Provide</b></p><ul><li>
Referral bonus opportunities
</li><li>Generous paid time off (PTO), starting at <b>30 days of paid time off</b><b> </b>and 9 company holidays
</li><li>Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability
</li><li>Employer-matched retirement saving funds
</li><li>Personal and financial wellness programs
</li><li>Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care</li><li>
Generous tuition reimbursement for qualifying degrees
</li><li>Opportunities for professional growth and career advancement
</li><li>Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities</li></ul><p></p><p><b><br>
What You Will Do</b></p><ul><li>
Runs cost avoidance reports to analyze and validate managed care claims and comp grids against provider contracts, member eligibility, benefit grids, and authorization data to ensure VNS Health pays our providers appropriately and contains cost.</li><li>
Investigates utilization and claims coding patterns to identify potential fraud, waste or abuse and coordinates with Compliance and Special Investigation Unit for recoveries as necessary.</li><li>
Analyzes affordability of medical cost against premium revenue for membership panels of providers, in specific settings, or across other attribution categories as appropriate.</li><li>
Communicates with internal departments (i.e., Claims, Providers, Finance etc.) to validate existence of integrity leakage points, and coordinates to develop and implement corrective solutions and recovery.</li><li>
Analyzes recovery and negative balance dashboard validating accuracy, timeliness, and performance of recoveries</li><li>
Attends meetings with analytics teams, product teams, operations, and allied departments to communicate status of investigative projects and identify new areas of opportunity or priorities. Keeps management informed as necessary.</li><li>
Utilizes analytic data warehouse and native claims systems and other supporting data for investigation.</li><li>
Conducts targeted analysis to support regulatory investigations; provides claims extracts and supporting data as required.</li><li>
Assists encounter team in ensuring alignment of claims to encounters.</li><li>
Maintains check request and recovery letter trackers assuring reviews are done timely and recovery payments from providers are logged appropriately.</li><li>
Participates in special projects and performs other duties as assigned.</li></ul>
<br>
<b>Qualifications</b><p><b><br>
Education:
</b><br>
Bachelor's Degree Bachelor&rsquo;s degree required preferably in Technology, Information Science, Mathematics or Statistics or the equivalent work experience required<br>
<br>
<b>Work Experience:</b>
<br>
Minimum of three years managed care claims analysis experience required</p><p>
Experience in financial or operational analytics preferred</p><p>
Knowledge of Medicare and NYS Medicaid claims processing rules and coding experience with DRG, ICD10 and CPT4 required</p><p>
Proficiency in standard business applications such as Microsoft Office required</p><p>
Proficiency in claims processing platforms such as FACETS required</p><p>
Proficiency in data analysis software such as SAS, R, or Stata preferred</p><p>
Proficiency with SQL. preferred Excellent communication and analytical skills required<br>
<br>
<br>
</p><br>
<b>Pay Range</b><br>
<br>
USD $77,200.00 - USD $96,500.00 /Yr.
<br>
<b>About Us</b><br>
<br>
<b>VNS Health</b> is one of the nation&rsquo;s largest nonprofit home and community-based health care organizations. Innovating in health care for more than 130 years, our commitment to health and well-being is what drives us &mdash; we help people live, age and heal where they feel most comfortable, in their own homes, connected to their family and community. On any given day, more than 10,000 VNS Health team members deliver compassionate care, unparalleled expertise and 24/7 solutions and resources to the more than 43,000 &ldquo;neighbors&rdquo; who look to us for care. Powered and informed by data analytics that are unmatched in the home and community-health industry, VNS Health offers a full range of health care services, solutions and health plans designed to simplify the health care experience and meet the diverse and complex needs of the communities and people we serve in New York and beyond.</div>

Senior Cost Containment Analyst

SCOR

<div><p>Senior Claim Experts are hands-on managers of individual higher exposure/complicated claims; expected to regularly conduct outside claim audits, market and client visits; initiate regular contact with underwriters, actuaries and accounting staff; and have the ability to review and analyse overall loss portfolios. A comfort level with technology is required as the digitalization of our departmental operations is a key part of our corporate strategy. While many meetings can be conducted remotely, the role will require business travel from time to time. The position reports to the Vice President Head of Claims - Americas.</p></div>
<br><div><ul><li><p>Oversee and manage a portfolio of Excess Casualty (General Liability, Umbrella, Wrap policies) insurance claims P&amp;C accounts which entails:
</p></li><li><p>Superior claim knowledge and expertise
</p></li><li><p>E valuating, developing, reporting on and resolving complex and/or higher value claims and/or loss bordereaux.
</p></li><li><p>Capability to develop market lead status in market committees or litigation.
</p></li><li><p>Ability to formulate independent views on coverage, liability and quantum and provide timely reporting.
</p></li><li><p>Approving financial transactions on claims within authority. This includes assessing and evaluating liability, coverage, and quantum, as well as establishing and updating reserves (as appropriate).
</p></li><li><p>Manage the lifecycle of a claim to achieve an optimal outcome for Scor, including the positioning of reserves, engagement of third parties (including but not limited to legal counsel, loss adjusters, forensic accountants etc), attendance at market/settlement meetings and/or forums for the resolution of the claim (mediation, arbitration, court etc).
</p></li><li><p>Collaborating and assisting in the management of assigned accounts or product line business, often with other internal department representatives and providing marketing support relating to cedents, insured and/or brokers.
</p></li><li><p>Conducting claim audits and/or participating in active reviews of service providers and providing marketing support relating to insureds, cedents, and brokers.
</p></li><li><p>Analyzing loss and expense trends on product line business, emerging risks and large losses; assisting in the development and implementation of plans to improve results.
</p></li><li><p>Anticipating client needs and expectations and delivering superior customer service.
</p></li><li><p>Working collaboratively with others within the claim department, particularly with other claim experts and those staffing the claim analyst or technical accounting unit, to ensure prompt turnaround and response to clients.
</p></li><li><p>Excellent organizational skills and ability to consistently meet deadlines. High degree of accountability, both personally and within the team.
</p></li><li><p>Contributing to the company&rsquo;s international community of claims expertise by sharing knowledge and experience on a global basis.
</p></li><li><p>Keeping abreast of claim and industry developments/trends in order to maintain a high level of expertise.
</p></li><li><p>Leading or participating in projects as required.
</p></li><li><p>Coaching, mentoring, and assisting in the training of more junior claim staff.
</p></li><li><p>Participate in operational performance reviews and establish a culture of continuous improvement to support overall claim strategy of providing a &ldquo;Centre of Excellence&rdquo; in claims.
</p></li><li><p>Excellent verbal and written communication skills. At ease with presenting findings, ideas, and other information in front of a group at Senior Management level.
</p></li><li><p>Participating in projects as required.</p></li></ul></div>
<br><p></p><div><ul><li>10+ years of Product line business P&amp;C claim handling experience.
</li><li>Expertise in managing a caseload of more complex claims.
</li><li>Ability to manage and organize and analyze data.
</li><li>Some managerial experience is a positive; whether people, projects and/or accounts.
</li><li>Handling of claims across international geographies a benefit.
</li></ul><p><b>Personal Competences:
</b></p><ul><li>Superior claim knowledge and expertise.
</li><li>Acute focus on customer service.
</li><li>Strong persuasive and people management skills.
</li><li>Developing experience in leadership in client engagement and/or litigation dispute resolution.
</li><li>Effective in communicating all trends and major claim for product lines within the business area.
</li><li>Exceptional team player while capable of operating independently.
</li><li>Excellent verbal and written communication skills. Able to write technical claims reports for segment at a high standard for distribution at senior leadership level.
</li><li>Ability to analyze data and information.
</li><li>At ease with presenting findings, ideas, and other information in front of a group. Ability to marshal resources to achieve desired outcomes.
</li><li>Comfort level with technology.
</li><li>A thought leader, particularly within the product line business, leading on initiatives and driving innovation.
</li><li>Holds self to account; owns the solution and takes personal responsibility and accountability.
</li><li>Comfortable having challenging conversations, including 360 feedback, constructively critical and analytical.
</li>Sets example of honesty, integrity, and respectfulness in all dealings.<br>
<li>
</li></ul><p></p><div><b>Relocation assistance within the U.S. is available for this position. Candidates must have valid authorization to work in the U.S. without the need for employer sponsorship now or in the future.<br>
</b></div><div></div><div><b><i>Hybrid Work Policy: </i></b><i>SCOR is committed to an &ldquo;in-office&rdquo; culture where people can collaborate, exchange ideas, and establish stronger working relationships while still providing flexibility. To support employee work-life balance and increase opportunities for employees to excel every day, SCOR operates with a hybrid working arrangement. SCOR employees work 3 days per week in an office with the flexibility to work 2 days per week remotely.<br>
</i></div><div></div><div><i>At SCOR, we CARE about clients, people, and societies, and we are committed to placing them at the center of everything we do. Providing great benefit choices to you and your family is just one of the ways we support the physical, financial, and emotional well-being of the people who make our company successful &ndash; you.<br>
</i></div><div></div><div><b><i>Benefits We Offer
</i></b></div><div><i>&bull; Medical, vision, and dental coverage
</i></div><div><i>&bull; 401(k) Plan with a competitive match
</i></div><div><i>&bull; Company-funded Defined Contribution Retirement Program
</i></div><div><i>&bull; Life and AD&amp;D insurance
</i></div><div><i>&bull; Long- and Short-Term Disability
</i></div><div><i>&bull; Flexible Parental Leave
</i></div><div><i>&bull; Unlimited Sick Days
</i></div><div><i>&bull; Volunteer Time
</i></div><div><i>&bull; Summer Fridays
</i></div><div><i>&bull; Learning &amp; Development Resources
</i></div><div><i>&bull; Personal Wellness Tools and Rewards
</i></div><div><i>&bull; Competitively priced gym memberships from a large nationwide network of gym brands and local fitness studios
</i></div><div><i>&bull; And More!<br>
</i></div><div></div><div><i>SCOR welcomes and encourages applications from people with disabilities. Accommodations are available on request for candidates taking part in all aspects of the selection process.<br>
</i></div><div></div><div><b><i>Compensation: </i></b><i>Pay Range for roles performed in Illinois: $[136,500 - 184,500] base salary per year. Pay Range for roles performed in New York: $[148,000 - 200,500] base salary per year. Actual salaries may vary based on various factors including but not limited to location, experience, role and performance. The range listed is just one component of SCOR's total compensation package for employees. Other rewards may include annual bonuses, short- and long-term incentives. In addition, we provide a variety of benefits to employees, including health insurance coverage, life and disability insurance, a retirement saving plan, paid holidays and paid time off.&quot;</i></div></div><div></div>
<br><div><p>As a leading global reinsurer, SCOR offers its clients a diversified and innovative range of reinsurance and insurance solutions and services to control and manage risk. Applying &ldquo;The Art &amp; Science of Risk,&rdquo; SCOR uses its industry-recognized expertise and cutting-edge financial solutions to serve its clients and contribute to the welfare and resilience of society in around 160 countries worldwide.
</p><p>Working at SCOR means engaging with some of the best minds in the industry &ndash; actuaries, data scientists, underwriters, risk modelers, engineers, and many others &ndash; as we work together to find solutions to pressing challenges facing societies.
</p><p>As an international company, our common culture is defined by &ldquo;The SCOR Way.&rdquo; Serving both to build momentum that drives the Group forward and as a compass to guide our actions and choices, The SCOR Way is anchored by five core values, reflecting the input of employees at all levels of the Group. We care about clients, people, and societies. We perform with integrity. We act with courage. We encourage open minds. And we thrive through collaboration.
</p><p>SCOR supports inclusion and the diversity of talents, and all positions are open to people with disabilities.</p></div>

AVP, Senior Claims Expert

Gallagher

<div><b>Introduction</b><br>
<div>
At Gallagher, we help clients face risk with confidence because we believe that when businesses are protected, they&rsquo;re free to grow, lead, and innovate. You&rsquo;ll be backed by our digital ecosystem: a client-centric suite of consulting tools making it easier for you to meet your clients where they want to be met. Advanced data and analytics providing a comprehensive overview of the risk landscape is at your fingertips. Here, you&rsquo;re not just improving clients' risk profiles, you&rsquo;re building trust. You&rsquo;ll find a culture grounded in teamwork, guided by integrity, and fueled by a shared commitment to do the right thing. We value curiosity, celebrate new ideas, and empower you to take ownership of your career while making a meaningful impact for the businesses we serve. If you&rsquo;re ready to bring your unique perspective to a place where your work truly matters; think of Gallagher.</div><div><br>
</div><br>
<b>Overview</b><div><br>
The Gallagher National Risk Control Team is now the Gallagher Claims and Risk Consulting Team. This new team is equipped with experts, processes and solutions to help you meet the evolving nature of risk. As risk evolves, so has Gallagher with tools and programs to help you proactively meet these challenges now and in the future. Gallagher's Claims and Risk Consulting team includes more than 100 safety and risk control professionals across the country with in-depth knowledge of current and emerging regulations, safety and health management, and operational exposures. The position is full-time remote.</div><br>
<br>
<b>How you'll make an impact</b><br>
<ul><li>
Consult on appropriate claims strategy with brokers and clients</li><li>
Analyze claims and policies for reporting claims to insurers</li><li>
Report claims in timely and appropriate manner</li><li>
Manage communications between clients, insurers and brokers to move the claims process forward</li><li>
Advocate for clients to maximize results</li><li>
Negotiate with insurers to ensure proper defense counsel arrangements, granting of consents to settlement and otherwise, and timely issuance of coverage letters
</li><li>Exercise judgment in escalating complicated or high-exposure claims
</li><li>Engage proactively to drive the claims process in a timely and appropriate manner</li><li>
Provide insight and claims information during claims reviews and sales pitches</li><li>
Assist the broker team with questions on claims, policy language reviews, and presentations to current and prospective clients</li><li>
Maintain claims information and documentation in approved diary system and databases</li></ul>
<br>
<b>About You</b><br>
<ul><li>
3 years of relevant claims experience, with adjuster experience preferred</li><li>
Advanced proficiency with Microsoft Word, Outlook, Excel, and PowerPoint</li><li>
Exceptional verbal, written and interpersonal communication skills, including responsiveness</li><li>
Excellent analytical, time management, and organizational skills, including ability to multi-task, prioritize, and manage large volumes of information</li></ul><div>
#LI-MS1</div><br>
<br>
<b>Compensation and benefits</b><p><br>
We offer a competitive and comprehensive compensation package. The base salary range represents the anticipated low end and high end of the range for this position. The actual compensation will be influenced by a wide range of factors including, but not limited to previous experience, education, pay market/geography, complexity or scope, specialized skill set, lines of business/practice area, supply/demand, and scheduled hours. On top of a competitive salary, great teams and exciting career opportunities, we also offer a wide range of benefits.
</p><p>Below are the <b>minimum core benefits</b> you&rsquo;ll get, depending on your job level these benefits may improve:
</p><ul><li>Medical/dental/vision plans, which start from day one!</li><li>
Life and accident insurance</li><li>
401(K) and Roth options</li><li>
Tax-advantaged accounts (HSA, FSA)</li><li>
Educational expense reimbursement</li><li>
Paid parental leave</li></ul><div><b>
Other benefits include:</b></div><ul><li>
Digital mental health services (Talkspace)</li><li>
Flexible work hours (availability varies by office and job function)</li><li>
Training programs</li><li>
Gallagher Thrive program &ndash; elevating your health through challenges, workshops and digital fitness programs for your overall wellbeing</li><li>
Charitable matching gift program</li><li>
And more...</li></ul><div><i>
**The benefits summary above applies to fulltime positions. If you are not applying for a fulltime position, details about benefits will be provided during the selection process.</i></div><div></div><div><b><br>
We value inclusion and diversity</b></div><p>
Click Here to review our U.S. Eligibility Requirements</p><p>
Inclusion and diversity (I&amp;D) is a core part of our business, and it&rsquo;s embedded into the fabric of our organization. For more than 95 years, Gallagher has led with a commitment to sustainability and to support the communities where we live and work.
</p><p>Gallagher embraces our employees&rsquo; diverse identities, experiences and talents, allowing us to better serve our clients and communities. We see inclusion as a conscious commitment and diversity as a vital strength. By embracing diversity in all its forms, we live out The Gallagher Way to its fullest.</p><p>
Gallagher believes that all persons are entitled to equal employment opportunity and prohibits any form of discrimination by its managers, employees, vendors or customers based on race, color, religion, creed, gender (including pregnancy status), sexual orientation, gender identity (which includes transgender and other gender non-conforming individuals), gender expression, hair expression, marital status, parental status, age, national origin, ancestry, disability, medical condition, genetic information, veteran or military status, citizenship status, or any other characteristic protected (herein referred to as &ldquo;protected characteristics&rdquo;) by applicable federal, state, or local laws.
</p><p>Equal employment opportunity will be extended in all aspects of the employer-employee relationship, including, but not limited to, recruitment, hiring, training, promotion, transfer, demotion, compensation, benefits, layoff, and termination. In addition, Gallagher will make reasonable accommodations to known physical or mental limitations of an otherwise qualified person with a disability, unless the accommodation would impose an undue hardship on the operation of our business.</p></div>

Advocate

Zurich Insurance

<div><div>Zurich North America Claims we acknowledge that work life-balance and flexibility are a priority when it comes to choosing your next career move. Designed with our employees' needs in mind, the ZNA Claims hybrid work model emphasizes flexibility, allowing claims employees to conduct individual work in their preferred location, while facilitating in-person connections and collaborative activities when meaningful and valuable. While the model provides a high level of flexibility and autonomy, occasional circumstances requiring in-office attendance should be expected. The candidate selected for this opportunity should be able to report into the following North American Claims office: <b>Parsippany, New Jersey or New York World Trade Center.</b></div><div></div><div><br>
Zurich is currently looking for a Legal Claims Professional for our Professional Programs group.</div><div></div><div><br>
The Claims professional will under limited supervision handle Professional Liability claims of moderate to high complexity. The ideal candidate will have experience reviewing complaints and all other legal pleadings and discovery, arbitration demands, coverage analysis, determining exposure and setting appropriate reserves. They will resolve claims according to Best Practices and within authority limits and will regularly communicate with customers and brokers and will be dedicated to handle claims for specific programs.</div><div></div><div><br>
Additional responsibilities include:</div><br>
<div></div><ul><li>
Analyze coverage; Draft and issue clear, timely coverage determinations.</li><li>
Investigate liability and damages exposure for claims</li><li>
Participate in mediations and negotiation of settlements</li><li>
Maintain accurate file documentation, reserves, and reporting in compliance with internal and regulatory standards.</li><li>
Communicate effectively with insureds, brokers, and program administrators including notifying underwriters of claim issues and trends</li><li>
Draft case summary reports in connection with significant reserve increases and trial preparation</li><li>
Manage defense counsel and litigation strategies within established guidelines and budgetary restraints.</li></ul><div></div><div><br>
Basic Qualifications:</div><br>
<div></div><ul><li>
Juris Doctor and 5 or more years of experience in the Legal area</li><li>
AND</li><li>
JD and 5 or more years of legal practice experience in the insurance area</li><li>
Must obtain and maintain required adjuster license(s)</li><li>
Experience in insurance claims and the insurance legal and regulatory environment</li><li>
Negotiation experience</li><li>
Customer service experience</li><li>
Microsoft Office experience</li></ul><div></div><div><br>
Preferred Qualifications:</div><br>
<div></div><ul><li>
Member of the Bar</li><li>
Claims handling experience with at least 5 or more years in EPL, E&amp;O and/or insurance coverage defense</li><li>
Analytical skills</li><li>
Strong communication skills</li><li>
Ability to multi-task</li><li>
Organization and time management skills</li><li>
Ability to work independently</li><li>
Experience collaborating across work groups</li><li>
Insurance designations such as SCLA, CPCU, AIC</li></ul><div></div><p><br>
</p><p>Your pay at Zurich is based on your role, location, skills, and experience. We follow local laws to ensure fair compensation. You may also be eligible for bonuses and merit increases. If your expectations are above the listed range, we still encourage you to apply&mdash;your unique background matters to us. The pay range shown is a national average and may vary by location. The proposed Salary range for this position is $140,000.00 - $165,000.00, with short-term incentive bonus eligibility set at 15%.</p><p></p><p><br>
We offer competitive pay and comprehensive benefits for employees and their families. [Learn more about Total Rewards here.]</p><p></p><p><b><br>
Why Zurich?</b></p><p>
At Zurich, we value your ideas and experience. We offer growth, inclusion, and a supportive environment&mdash;so you can help shape the future of insurance. Zurich North America is a leader in risk management, with over 150 years of expertise and coverage across 25+ industries, including 90% of the Fortune 500&reg;.</p><p></p><p><br>
Join us for a brighter future&mdash;for yourself and our customers.</p><p></p><p><br>
Zurich in North America does not discriminate based on race, ethnicity, color, religion, national origin, sex, gender expression, gender identity, genetic information, age, disability, protected veteran status, marital status, sexual orientation, pregnancy or other characteristics protected by applicable law. Equal Opportunity Employer disability/vets.</p><p></p><p><br>
Zurich complies with 18 U.S. Code &sect; 1033.</p><p></p><p><b><br>
Please note:</b> Zurich does not accept unsolicited CVs from agencies. Preferred vendors should use our Recruiting Agency Portal.</p><p>
Location(s): AM - New York, AM - Parsippany<br>
Remote Working: Hybrid<br>
Schedule: Full Time<br>
Employment Sponsorship Offered: No<br>
<br>
Linkedin Recruiter Tag: #LI-LC1 #LI-ASSOCIATE #LI-HYBRID</p></div>

Legal Claims Handler -Professional Lines

NYC Health + Hospitals

<div><div><div><h2 class="jobSectionHeader"><b>About NYC Health + Hospitals</b></h2><div><br>
<div><div>
</div><p>MetroPlus<b>Health</b> provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus<b>Health</b>'s network includes over 27,000 primary care providers, specialists and participating clinics. For more than 40 years, MetroPlus<b>Health</b> has been committed to building strong relationships with its members and providers.</p><p><b>
Position Overview</b></p><p>
As a Claims Adjustment Specialist I, this individual will be responsible for analyzing standard to complex post-paid healthcare claims that require in depth research to determine accuracy and mitigate payment errors. The Claims Adjustment Specialist I will also be responsible for adjusting medical claims that result in overpayment or underpayment due to claim processing system issues, contract amendments, processing errors, or other issues. This position will be responsible for responding to inquiries from providers whose claims may be paid incorrectly and performing accurate data entry and maintenance accurate records and files.</p><br>
</div></div></div></div><div><div><h2 class="jobSectionHeader"><b>
Work Shifts</b></h2><div><br>
<div><div>
</div><p><b>9:00 A.M &ndash; 5:00 P.M</b></p><br>
</div></div></div></div><div><div><h2 class="jobSectionHeader"><b>
Duties &amp; Responsibilities</b></h2>
<div>
<div></div><div><ul><li>High School Degree or evidence of having passed a High School Equivalency Program required. Associate degree preferred.</li><li>
Minimum 2 years of claims operations experience in a healthcare field, with knowledge of integrated claims processing required.</li><li>
Experience using a PC and claim adjudication system(s)</li><li>
Experience using Customer Relationship Management (CRM) software; Salesforce is a plus.</li><li>
Experience working with large data and spreadsheets.</li><li>
Knowledge of medical terminology, CPT, ICD-10, and Revenue Codes</li><li>
Processing of Medical Claim Forms (HCFA, UB04)</li><li>
Knowledge of Medical Terminology</li><li>
Knowledge of HIPPA Guidelines regarding Protected Health Information</li><li>
Data Entry of Provider Claim/Billing information</li><li>
Experience handling or familiarity with Medical Claim inquiries from provider sites personnel including physicians, clinical staff, and site administrators.</li></ul><p><b>
Professional Competencies</b></p><ul><li>
Integrity and Trust</li><li>
Customer Focus</li><li>
Functional/Technical skills</li><li>
Written/Oral Communication</li><li>
Strong Analytical Skills</li><li>
Knowledgeable in MS Word and Excel</li></ul>
</div></div></div></div><div><div><h2 class="jobSectionHeader"><b>Benefits</b></h2><div><br>
<div><div>
</div><p>NYC Health and Hospitals offers a competitive benefits package that includes:</p><ul><li>
Comprehensive Health Benefits for employees hired to work 20+ hrs. per week</li><li>
Retirement Savings and Pension Plans</li><li>
Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts</li><li>
Loan Forgiveness Programs for eligible employees</li><li>
College tuition discounts and professional development opportunities</li><li>
College Savings Program</li><li>
Union Benefits for eligible titles</li><li>
Multiple employee discounts programs</li><li>
Commuter Benefits Programs</li></ul></div></div></div></div></div>

Claims Adjustment Specialist I

<div><p>Zurich is currently looking for a Legal Claims Professional for our growing Management Solutions group.</p><p><br>
If you are ready for a career move, consider working for a company with a global footprint that offers terrific benefits including an incentive plan, 401K match and an additional 401K contribution, flexible work options, work/life balance, summer hours and a great culture.</p><p><br>
The Claims Professional will handle Private/Non-Profit D&amp;O, EPL, and Fiduciary claims of moderate to high complexity under limited supervision. The ideal candidate will have experience reviewing complaints and all other legal pleadings and discovery, arbitration demands, coverage analysis, determining exposure and setting appropriate reserves. They will resolve claims according to Best Practices and within authority limits. They will regularly communicate with customers and brokers and may be dedicated to handle claims for specific accounts.<br>
</p><p><br>
Additional responsibilities include:<br>
</p><p></p><ul><li>Analyze coverage, liability, damages and exposure</li><li>
Participate in mediations and settlement negotiations</li><li>
Draft reservation of rights and coverage denial letters</li><li>
Notify Underwriter of claim issues</li><li>
Draft case summary reports in connection with significant reserve increases and trial preparation</li><li>
Direct and engage with the activities of defense counsel</li></ul><p></p><p><br>
At Zurich North America we acknowledge that work life-balance and flexibility are a priority when it comes to choosing your next career move. Designed with our employees' needs in mind, the ZNA hybrid work model emphasizes flexibility, allowing claims employees to conduct individual work in their preferred location, while facilitating in-person connections and collaborative activities when meaningful and valuable. While the model provides a high level of flexibility and autonomy, occasional circumstances requiring in-office attendance should be expected. The candidate selected for this opportunity should be able to report into our Manhattan NY; Parsippany NJ; or Schaumburg IL office on a hybrid schedule.</p><p></p><p><br>
Basic Qualifications:<br>
<br>
<br>
</p><ul><li>Juris Doctor and 5 or more years of experience in the Legal area<br>
AND</li><li>
JD and 5 or more years of legal practice experience in the insurance area
</li><li>Must obtain and maintain required adjuster license(s)</li><li>
Experience in insurance claims and the insurance legal and regulatory environment</li><li>
Negotiation experience</li><li>
Customer service experience</li><li>
Microsoft Office experience</li></ul><div></div><div><br>
Preferred Qualifications:<br>
<br>
<br>
</div><ul><li>Member of the Bar</li><li>
Claims handling experience including Private/Non-Profit D&amp;O, EPL, Fiduciary and/or insurance coverage defense</li><li>
Analytical skills</li><li>
Strong communication skills</li><li>
Ability to multi-task</li><li>
Organization and time management skills</li><li>
Ability to work independently</li><li>
Experience collaborating across work groups</li><li>
Insurance designations such as SCLA, CPCU, AIC</li></ul><div></div><p><br>
</p><p>Your pay at Zurich is based on your role, location, skills, and experience. We follow local laws to ensure fair compensation. You may also be eligible for bonuses and merit increases. If your expectations are above the listed range, we still encourage you to apply&mdash;your unique background matters to us. The pay range shown is a national average and may vary by location. The proposed Salary range for this position is $135,000.00 - $165,000.00, with short-term incentive bonus eligibility set at 15%.</p><p></p><p><br>
We offer competitive pay and comprehensive benefits for employees and their families. [Learn more about Total Rewards here.]</p><p></p><p><b><br>
Why Zurich?</b></p><p>
At Zurich, we value your ideas and experience. We offer growth, inclusion, and a supportive environment&mdash;so you can help shape the future of insurance. Zurich North America is a leader in risk management, with over 150 years of expertise and coverage across 25+ industries, including 90% of the Fortune 500&reg;.</p><p></p><p><br>
Join us for a brighter future&mdash;for yourself and our customers.</p><p></p><p><br>
Zurich in North America does not discriminate based on race, ethnicity, color, religion, national origin, sex, gender expression, gender identity, genetic information, age, disability, protected veteran status, marital status, sexual orientation, pregnancy or other characteristics protected by applicable law. Equal Opportunity Employer disability/vets.</p><p></p><p><br>
Zurich complies with 18 U.S. Code &sect; 1033.</p><p></p><p><b><br>
Please note:</b> Zurich does not accept unsolicited CVs from agencies. Preferred vendors should use our Recruiting Agency Portal.</p><p>
Location(s): AM - New York, AM - Parsippany, AM - Schaumburg<br>
Remote Working: Hybrid<br>
Schedule: Full Time<br>
Employment Sponsorship Offered: No<br>
<br>
Linkedin Recruiter Tag: #LI-KO1 #LI-ASSOCIATE #LI-HYBRID</p></div>

Legal Claims Professional - Financial Lines

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