claims examiner ii

The Baldwin Group

<p></p><div><div><h2 class="jobSectionHeader"><b>Why MSI? We thrive on solving challenges.
</b></h2></div><p></p><div><div><div><div><div><div><div><div><div><p><b>As a leading MGA, MSI combines deep underwriting expertise with insurer and reinsurer risk capacity to create specialized insurance solutions that empower distribution partners to meet customers&rsquo; unique needs.
</b></p><p></p><p><b>We have a passion for crafting solutions for the important risks facing individuals and businesses. We offer an expanding suite of products &ndash; from fully-digital embedded renters coverage to high-value homeowners insurance to sophisticated commercial coverages, such as cyber liability and habitational property &ndash; delivered through agents, brokers, wholesalers and other brand partners.
</b></p><p></p><p><b>Our partners and customers count on us to deliver exceptional service through a dedicated team that makes rapid resolutions a priority. We simplify the insurance experience through our advanced technology platform that supports every phase of the policy lifecycle.
</b></p><p></p><p><b>Bring on your challenges and let us show you how we build insurance better.
</b></p><p></p><p>The Claims Examiner II is considered an expert in managing insurance claims for our policyholders, handling claims with a higher level of complexity. The Claims Examiner II must have technical knowledge in insurance claims handling and the skills needed to provide superior service for our customers. The ability to develop relationships and effectively communicate with a diverse range of clients, carriers and colleagues is a key success factor in this role. Strategic vision coupled with tactical execution to achieve results in accordance with goals and objectives is also critical to the overall success of this position
</p></div></div></div></div></div></div></div></div></div><p></p><div>PRIMARY RESPONSIBILITIES:
<br>
<ul><li>Analyzes insurance policies and other documents to determine insurance coverage.
</li><li>Investigates and analyzes claim information to determine extent of liability.
</li><li>Handles claims 1st Party Property Claims of a high level of complexity.
</li><li>Assist in suits, mediations and arbitrations. Works with Counsel in the defense of litigation.
</li><li>Sets timely, adequate reserves in compliance with the company&rsquo;s reserving philosophy.
</li><li>Engages experts to assist in the evaluation of the claim.
</li><li>Monitors vendor performance and controls expense costs.
</li><li>Evaluates, negotiates and determines settlement values.
</li><li>Communicates with all interested parties throughout the life of the claim. Proactively discusses coverage decisions, the need for additional information, and settlement amounts with interested parties.
</li><li>Handles all claims in accordance with Best Practices.
</li><li>Responsible for monitoring and completing assigned claims inventory.
</li><li>Acquire and maintain a state adjuster&rsquo;s license and meet state continuing education requirements.
</li><li>Provides Best-In-Class customer service for insureds and agents.
</li><li>Updates and maintains the claim file.
</li><li>Identifies opportunities for subrogation and ensures recovery interests are protected.
</li><li>Identifies fraud indicators and refers files to SIU for further investigation.
</li><li>Participates in claims audits, internal and external.
</li><li>Provides oversight of TPAs
</li></ul><br>
KNOWLEDGE, SKILLS &amp; ABILITIES:
<br>
<br>
EDUCATION &amp; EXPERIENCE:
<br>
High School/GED
<br>
5-9 years' experience in claims
<br>
Must have Property &amp; Casualty Insurance License
 </div><p></p><p>#LI-JW2
</p><p>#LI-REMOTE</p><p></p><p><br>
</p><p></p><p>The Baldwin Group will not accept unsolicited resumes from any source other than directly from a candidate who applies on our career site. Any unsolicited resumes sent to The Baldwin Group, including unsolicited resumes sent via any source from an Agency, will not be considered and are not subject to any fees for any placement resulting from the receipt of an unsolicited resume.</p></div>

Claims Examiner II- MSI

TEEMA Group

<div><p><b>Role Summary</b></p><p>
The Claims Examiner II/III is a senior-level professional responsible for managing the full lifecycle of workers&rsquo; compensation indemnity claims, from inception through resolution, within established authority and guidelines. This role handles highly complex claims and plays a critical part in ensuring compliance with state regulations, timely investigations, accurate reserving, and effective claim resolution. The position requires strong analytical judgment, excellent communication skills, and consistent collaboration with clients, claimants, vendors, legal counsel, and internal teams.</p><p>
This is an excellent opportunity for an experienced claims professional seeking autonomy, complexity, and impact in a hybrid work environment.</p><p>
 <b>Duties and Responsibilities</b></p><ul><li><p>
Manage a caseload of approximately 125&ndash;150 workers&rsquo; compensation claims, including highly complex and litigated files.</p></li><li><p>
Handle claims within Pennsylvania and New Jersey jurisdictions in compliance with applicable state laws and company guidelines.</p></li><li><p>
Initiate and conduct timely, thorough investigations to determine compensability.</p></li><li><p>
Administer benefits and manage claims in accordance with statutory requirements and organizational policies.</p></li><li><p>
Oversee medical treatment and medical billing, authorizing services as appropriate.</p></li><li><p>
Refer claims to outside defense counsel and direct legal strategy as needed.</p></li><li><p>
Communicate effectively with claimants, medical providers, vendors, clients, and internal stakeholders regarding claim status and issues.</p></li><li><p>
Establish and manage claim reserves within company guidelines, with higher authority limits than lower-level examiner roles.</p></li><li><p>
Negotiate, settle, and finalize claims, obtaining appropriate settlement authority when required.</p></li><li><p>
Maintain accurate and well-documented claim files, including diary systems for timely case review.</p></li><li><p>
Proactively communicate relevant information to clients to promote efficient claim resolution and identify injury trends or safety concerns.</p></li><li><p>
Collaborate with loss control staff when appropriate to address risk management opportunities.</p></li><li><p>
Conduct independent file reviews to ensure quality, compliance, and best practices.</p></li><li><p>
Adhere to all company policies, procedures, and performance standards.</p></li><li><p>
Perform other related duties as assigned.</p></li></ul><p>
 <b>Required Qualifications</b></p><ul><li><p>
Bachelor&rsquo;s degree in a related field (preferred).</p></li><li><p>
Minimum of three (3) years of workers&rsquo; compensation claims experience, or an equivalent combination of education and experience.</p></li></ul><ul><li><p>
Strong technical knowledge of workers&rsquo; compensation statutory regulations and medical terminology.</p></li><li><p>
Advanced analytical and problem-solving skills.</p></li><li><p>
Excellent written and verbal communication skills, with the ability to clearly explain technical concepts to claimants, clients, and colleagues.</p></li><li><p>
Proven ability to interact professionally with individuals at all levels of an organization.</p></li><li><p>
Ability to independently manage highly complex and high-exposure claims with minimal supervision.</p></li><li><p>
Proficiency in Microsoft Word and Excel (preferred).</p></li></ul><p>
 <b>Desired Qualifications</b></p><ul><li><p>
Experience handling multi-state workers&rsquo; compensation claims.</p></li><li><p>
Prior experience managing litigation and working closely with defense counsel.</p></li><li><p>
Demonstrated success in settlement negotiation and reserve management.</p></li></ul><p><b>
Location and Work Type</b></p><ul><li><p><b>
Work Type:</b> REMOTE</p></li><li><p><b>
Office Presence:</b> Regular, timely attendance in the office is required due to the collaborative and client-facing nature of the role</p></li></ul><p></p><p><b>
If you're interested, please reply to this advertisement or directly email your resume to me at DSalgado@teemagroup.com or by calling/texting (949) 295-5951.</b></p><p><b>
I strive to reply within 48 hours. Looking forward to connecting with you soon. Thank you!</b></p>
#Workwolf</div>

Workers Compensation Claims Examiner II/III

TEEMA

<div><p><b>Overview:</b><br>
Our client, the largest Third Party Administrator in North America is looking for an experienced Claims Adjuster to handle Workers Compensation Claims. At the direction of the Claims Supervisor and/or Claims Manager, the Claims Adjuster/Examiner II / III manages all aspects of workers&rsquo; compensation indemnity, medical-only, future medical, and litigated claims from inception through resolution, within established authority and company/client guidelines. This role requires frequent interaction with clients, claimants, medical providers, attorneys, vendors, nurse case managers, vocational case managers, and internal staff. The level of complexity, litigation exposure, settlement authority, and leadership responsibility will be commensurate with the examiner&rsquo;s experience and designation (Level II or Level III).<br>
<br>
<b>What you will be doing:</b><br>
Applies to Examiner II &amp; III</p><ul><li><p>
Manage a full caseload of workers&rsquo; compensation claims, including complex indemnity claims.</p></li><li><p>
Initiate, conduct, and document timely and thorough claim investigations.</p></li><li><p>
Determine compensability and administer benefits in accordance with state laws, rules, and company/client handling instructions.</p></li><li><p>
Manage medical treatment and medical billing; authorize services as appropriate.</p></li><li><p>
Communicate effectively with claimants, medical providers, vendors, and clients regarding claim issues.</p></li><li><p>
Compute and set reserves in accordance with Company and Client guidelines.</p></li><li><p>
Maintain an organized diary system and document claim files to reflect status, strategy, and action plans.</p></li><li><p>
Settle and/or finalize claims and obtain appropriate settlement authority.</p></li><li><p>
Conduct scheduled file reviews and respond to client inquiries.</p></li><li><p>
Identify injury trends, safety concerns, and other claim-related issues and communicate proactively to clients.</p></li><li><p>
Adhere to all company policies, procedures, and best practices.</p></li><li><p>
Utilize office systems and technology efficiently to manage caseload responsibilities.</p></li><li><p>
Perform other related duties as assigned.</p></li></ul><p>
Advanced / Senior Responsibilities (Primarily Examiner III)</p><ul><li><p>
Manage very complex, catastrophic, and litigated indemnity claims from inception to conclusion.</p></li><li><p>
Refer cases to outside defense counsel and actively participate in litigation strategy, hearings, mediations, and settlements.</p></li><li><p>
Identify and manage:</p><ul><li><p>
Subrogation opportunities</p></li><li><p>
Apportionment potential</p></li><li><p>
Excess reporting criteria and reimbursement</p></li></ul></li><li><p>
Prepare and assist with state audits, regulatory reporting, and client-specific reporting requirements.</p></li><li><p>
Develop and execute proactive claim strategies to drive timely and cost-effective resolution.</p></li><li><p>
Conduct detailed client file reviews and participate in client meetings as needed.</p></li><li><p>
Mentor and provide technical guidance to less experienced Claims Examiners.</p></li><li><p>
Handle multi-jurisdictional workers&rsquo; compensation claims as assigned.</p></li></ul><p><b><br>
What you will be doing:</b><br>
Education &amp; Experience<br>
Claims Examiner II:</p><ul><li><p>
Bachelor&rsquo;s degree in a related field (preferred)</p></li><li><p>
Minimum 3+ years of workers&rsquo; compensation claims experience, or equivalent combination of education and experience</p></li></ul><p>
Claims Examiner III:</p><ul><li><p>
Minimum 5+ years of progressive workers&rsquo; compensation claims experience</p></li><li><p>
Demonstrated experience handling complex and litigated indemnity claims</p></li></ul><p>
Knowledge, Skills &amp; Abilities</p><ul><li><p>
Strong technical knowledge of workers&rsquo; compensation statutes, regulations, and medical terminology</p></li><li><p>
Ability to independently analyze and manage complex claims</p></li><li><p>
Excellent written and verbal communication skills</p></li><li><p>
Ability to convey technical information to claimants, clients, and internal stakeholders</p></li><li><p>
Strong organizational, analytical, and time-management skills</p></li><li><p>
Ability to interact professionally with individuals at all levels of the business environment</p></li><li><p>
Proficiency in Microsoft Word and Excel (preferred)</p></li></ul><p>
Certifications / Licenses</p><ul><li><p>
Hawaii Workers Compensation Adjusters License</p></li></ul><br>
<p></p>
#Workwolf</div>

Workers Compensation Claims Examiner II/III - Hybrid

Cala Sourcing Solutions LLC

<div><h2 class="jobSectionHeader"><b>Workers&rsquo; Compensation Claims Adjuster (Level II or III) &ndash; Hawaii</b></h2><p><b>
Location:</b> Kapolei, HI (Hybrid for local candidates | Remote for candidates outside the island but must be in Hawaii)</p><p></p><h3 class="jobSectionHeader"><b>
Position Summary</b></h3><p>
A leading Third Party Administrator is seeking an experienced Workers&rsquo; Compensation Claims Adjuster to manage a diverse caseload of Hawaii workers&rsquo; compensation claims. Reporting to Claims Leadership, this role is responsible for end-to-end claim ownership&mdash;from intake and investigation through resolution&mdash;while operating within established authority levels and client guidelines.</p><p>
This position involves regular collaboration with injured workers, employers, medical providers, attorneys, vendors, and internal partners. Claim complexity, litigation exposure, settlement authority, and leadership expectations will align with the Adjuster&rsquo;s level (Examiner II or Examiner III).</p><p></p><h3 class="jobSectionHeader"><b>
Core Responsibilities (Examiner II &amp; III)</b></h3><ul><li><p>
Oversee a full inventory of workers&rsquo; compensation claims, including medical-only, indemnity, future medical, and litigated files</p></li><li><p>
Conduct prompt and comprehensive claim investigations; document findings thoroughly and accurately</p></li><li><p>
Evaluate compensability and administer benefits in compliance with Hawaii statutes and applicable claim-handling instructions</p></li><li><p>
Coordinate medical care, authorize treatment, and manage medical billing activity</p></li><li><p>
Serve as the primary point of contact for claimants, employers, providers, vendors, and clients</p></li><li><p>
Establish, review, and adjust claim reserves in accordance with company and client standards</p></li><li><p>
Maintain detailed claim notes, action plans, and diary entries reflecting claim strategy and progress</p></li><li><p>
Negotiate, resolve, and close claims within assigned settlement authority</p></li><li><p>
Perform regular file reviews and respond to client inquiries in a timely manner</p></li><li><p>
Identify emerging trends, risk indicators, and safety concerns; communicate insights proactively</p></li><li><p>
Utilize claims systems and internal technology to manage workload efficiently</p></li><li><p>
Comply with all internal policies, procedures, and best practices</p></li><li><p>
Complete additional duties as assigned</p></li></ul><p></p><h3 class="jobSectionHeader"><b>
Advanced / Senior-Level Responsibilities (Primarily Examiner III)</b></h3><ul><li><p>
Independently manage highly complex, catastrophic, and litigated workers&rsquo; compensation claims</p></li><li><p>
Retain and collaborate with defense counsel; actively participate in hearings, mediations, and settlement negotiations</p></li><li><p>
Evaluate and pursue:</p><ul><li><p>
Subrogation opportunities</p></li><li><p>
Apportionment considerations</p></li><li><p>
Excess coverage reporting and reimbursement</p></li></ul></li><li><p>
Support regulatory compliance through audit preparation and state-required reporting</p></li><li><p>
Develop proactive claim strategies focused on timely, cost-effective resolution</p></li><li><p>
Participate in client file reviews and meetings as requested</p></li><li><p>
Provide mentoring and technical support to junior Claims Examiners</p></li><li><p>
Handle multi-jurisdictional claims when assigned</p></li></ul><p></p><h3 class="jobSectionHeader"><b>
Qualifications</b></h3><h4 class="jobSectionHeader"><b>
Education &amp; Experience</b></h4><p><b>
Claims Examiner II</b></p><ul><li><p>
Bachelor&rsquo;s degree in a related discipline preferred</p></li><li><p>
3+ years of workers&rsquo; compensation claims experience, or an equivalent combination of education and experience</p></li></ul><p><b>
Claims Examiner III</b></p><ul><li><p>
5+ years of progressive workers&rsquo; compensation claims experience</p></li><li><p>
Proven experience managing complex and litigated indemnity claims</p></li></ul><p></p><h3 class="jobSectionHeader"><b>
Knowledge, Skills &amp; Abilities</b></h3><ul><li><p>
Strong working knowledge of workers&rsquo; compensation laws, regulations, and medical terminology</p></li><li><p>
Ability to independently assess risk, analyze complex issues, and manage claims strategically</p></li><li><p>
Clear, professional written and verbal communication skills</p></li><li><p>
Strong organizational, analytical, and time-management capabilities</p></li><li><p>
Ability to communicate effectively with diverse stakeholders at all organizational levels</p></li><li><p>
Proficiency with Microsoft Word and Excel preferred</p></li></ul><p></p><h3 class="jobSectionHeader"><b>
Licensure</b></h3><ul><li><p>
Active <b>Hawaii Workers&rsquo; Compensation Adjuster License</b> required</p></li></ul>
#Workwolf</div>

Claims Supervisor - Workers Compensation

<div><p><b>Job Summary</b></p><p>
Workers Compensation Claims Examiner III</p><p>
TeemaGroup</p><p>
Full-time</p><p>
In-Office | Kapolei, HI, United States</p><p><b><br>
POSITION SUMMARY</b></p><p>
At the direction of the Claims Supervisor and/or Claims Manager, the Claims Examiner II / III manages all aspects of workers&rsquo; compensation indemnity, medical-only, future medical, and litigated claims from inception through resolution, within established authority and company/client guidelines.</p><p>
This role requires frequent interaction with <b>clients, claimants, medical providers, attorneys, vendors, nurse case managers, vocational case managers, and internal staff</b>.</p><p>
The <b>level of complexity, litigation exposure, settlement authority, and leadership responsibility</b> will be commensurate with the examiner&rsquo;s experience and designation (Level II or Level III).</p><p><b>
DUTIES AND RESPONSIBILITIES</b></p><p><b>
Core Responsibilities (Applies to Examiner II &amp; III)</b></p><ul><li>Manage a full caseload of workers&rsquo; compensation claims, including <b>complex indemnity claims</b>.</li><li>Initiate, conduct, and document timely and thorough claim investigations.</li><li>Determine compensability and administer benefits in accordance with <b>state laws, rules, and company/client handling instructions</b>.</li><li>Manage medical treatment and medical billing; authorize services as appropriate.</li><li>Communicate effectively with claimants, medical providers, vendors, and clients regarding claim issues.</li><li>Compute and set reserves in accordance with Company and Client guidelines.</li><li>Maintain an organized diary system and document claim files to reflect status, strategy, and action plans.</li><li>Settle and/or finalize claims and obtain appropriate settlement authority.</li><li>Conduct scheduled file reviews and respond to client inquiries.</li><li>Identify injury trends, safety concerns, and other claim-related issues and communicate proactively to clients.</li><li>Adhere to all TRISTAR company policies, procedures, and best practices.</li><li>Utilize office systems and technology efficiently to manage caseload responsibilities.</li><li>Perform other related duties as assigned.</li></ul><p><b>
Advanced / Senior Responsibilities (Primarily Examiner III)</b></p><ul><li>Manage <b>very complex, catastrophic, and litigated indemnity claims</b> from inception to conclusion.</li><li>Refer cases to outside defense counsel and actively participate in litigation strategy, hearings, mediations, and settlements.</li><li>Identify and manage:</li><li>Subrogation opportunities</li><li>Apportionment potential</li><li>Excess reporting criteria and reimbursement</li><li>Prepare and assist with <b>state audits, regulatory reporting, and client-specific reporting requirements</b>.</li><li>Develop and execute proactive claim strategies to drive timely and cost-effective resolution.</li><li>Conduct detailed client file reviews and participate in client meetings as needed.</li><li>Mentor and provide technical guidance to less experienced Claims Examiners.</li><li>Handle multi-jurisdictional workers&rsquo; compensation claims as assigned.</li></ul><p><i>
Essential job functions.</i></p><p></p><p><b>
QUALIFICATIONS REQUIRED</b></p><p><b>
Education &amp; Experience</b></p><ul><li><b>Claims Examiner II:</b></li><li>Bachelor&rsquo;s degree in a related field (preferred)</li><li>Minimum <b>3+ years</b> of workers&rsquo; compensation claims experience, or equivalent combination of education and experience</li><li><b>Claims Examiner III:</b></li><li>Minimum <b>5+ years</b> of progressive workers&rsquo; compensation claims experience</li><li>Demonstrated experience handling <b>complex and litigated indemnity claims</b></li></ul>
#Workwolf</div>

Workers Compensation Claims Examiner III

<div><p><b>Job Summary</b></p><p>
Workers Compensation Claims Examiner III</p><p>
TeemaGroup</p><p>
Full-time</p><p>
Hybrid | Philadelphia, PA, United States<br>
</p><p><br>
<b>The Opportunity</b></p><p>
You&rsquo;re the kind of person who is always looking to learn. You want to grow into something greater and you&rsquo;re looking for an employer encourages and supports your professional development. This is the largest privately held Third party claims administrator in the US.</p><p><b><br>
Responsibilities</b></p><ul><li><p>
Adjuster will work hybrid</p></li><li><p>
Effectively manages a caseload of 125 to 150 workers&rsquo; compensation files, including very complex claims. *</p></li><li><p>
Jurisdiction is PA and NJ. *</p></li><li><p>
Initiates and conducts investigation in a timely manner. *</p></li><li><p>
Determines compensability of claims and administer benefits, based upon state law and in accordance with established Company guidelines. *</p></li><li><p>
Manages medical treatment and medical billing, authorizing as appropriate. *</p></li><li><p>
Refers cases to outside defense counsel. Directs and manages as appropriate. *</p></li><li><p>
Communicates with claimants, providers and vendors regarding claims issues. *</p></li><li><p>
Computes and set reserves within Company guidelines. Limits are larger than those allowed for Claims Examiner I and Claims Examiner II. *</p></li><li><p>
Settles and/or finalize all claims and obtains authority as designated. *</p></li><li><p>
Maintains diary system for case review and documents file to reflect the status and work being performed on the file. *</p></li><li><p>
Communicates appropriate information promptly to the client to resolve claims efficiently, including any injury trends or other safety related concerns. *</p></li><li><p>
Involves TRISTAR loss control staff when appropriate. *</p></li><li><p>
Adheres to all Company policies and procedures. *</p></li><li><p>
Conducts file reviews independently. *</p></li><li><p>
Other duties as assigned.</p></li></ul><p><br>
Education/Experience: Bachelor&rsquo;s degree in related field (preferred); three (3) or more years related experience; or equivalent combination of education and experience.<br>
<br>
Knowledge, Skills and Abilities:</p><ul><li><p>
Technical knowledge of statutory regulations and medical terminology.</p></li><li><p>
Analytical skills.</p></li><li><p>
Excellent written and verbal communication skills, including ability to convey technical details to claimants, clients and staff.</p></li><li><p>
Ability to interact with persons at all levels in the business environment.</p></li><li><p>
Ability to independently and effectively manage very complex claims.</p></li><li><p>
Proficient in Word and Excel (preferred).</p></li></ul>
#Workwolf</div>

Delta Dental

<div><div><b>About Us</b></div><div></div><div><br>
Delta Dental of New Jersey and Delta Dental of Connecticut are proud to be leaders in the dental insurance industry, offering a wide range of plans to meet the needs of individuals and employers alike. As New Jersey&rsquo;s largest dental coverage provider, we are committed to delivering high-quality, cost-effective solutions designed to meet the diverse needs of our customers and our team is growing.</div><div></div><div><br>
In Connecticut, Delta Dental of Connecticut, Inc. provides fully insured dental coverage, while Delta Dental of New Jersey administers self-funded dental benefit programs. We proudly serve over 1.7 million individuals through more than 1,800 groups, including commercial, school board, and government programs.</div><div></div><div><br>
Since 1969, Delta Dental has been at the forefront of innovation, offering programs that control costs while ensuring the highest level of benefits.</div><div></div><div><br>
As a member of the national Delta Dental Plans Association, we provide national dental coverage to over 75 million people across 139,000 groups. Our commitment to excellence is reflected in our prestigious Standard &amp; Poor&rsquo;s &ldquo;A+&rdquo; rating for financial strength. Join us and be a part of a trusted company with a rich history of delivering quality dental benefits to millions.</div><div>
We value our associates and support everyone with learning and development, active wellness and diversity initiatives, and volunteer opportunities at causes that you care about.</div><div></div><div><b><br>
About the Position</b></div><div></div><div><br>
Our Claims Examiners are provided with established company guidelines and examine and adjudicate dental claims using these guidelines, with expected levels of quality and productivity.</div><div></div><div><br>
During the first five weeks of employment, you will participate in full‑time, paid training conducted in the office five days per week, Monday through Friday, from 8:30 a.m. to 4:30 p.m. Following the completion of training, this role will transition to a full‑time, hybrid schedule working Monday through Friday from 8:00 a.m. to 4:30 p.m., with in‑office days on Tuesday and Wednesday and remote work on Monday, Thursday, and Friday. This position starts at $22.05 per hour and is benefits-eligible.</div><div></div><p><br>
The expected Start date for this position is April 20th, 2026.</p><div></div><div><b><br>
Essential Functions &amp; Responsibilities</b></div><div><ul><li>
Accesses systems and keys claim data and other information and notations from work queues. Suspends, routes and adjudicates claims and performs research as required. Also, inputs fee filing data, as required</li></ul></div><div><ul><li>
Creates and processes claims for pre-treatment estimates with payments.</li></ul></div><div><ul><li>
Maintains and updates subscribers files with information obtained through inquiries and submitted claims and documents, i.e., family on hold codes applied or removed, student status deferred, addresses updated. Reports file discrepancies to management.</li></ul></div><div><ul><li>
Responsible for researching and retrieving all documentation and resolving all claims in question, including student documentation, provider research, some coordination of benefits, diagnostics materials, etc.</li></ul></div><div><ul><li>
Understands rejects and applies appropriate RFS codes as well as processing policies on applicable claims.</li></ul></div><div><ul><li>
Requests information from providers and subscribers through telephone contact or written correspondence.</li></ul></div><div><ul><li>
Resolves claims related system generated error and adjustment reports.</li></ul></div><div><ul><li>
Supports and participates in completing claims related projects.</li></ul></div><div><ul><li>
Acquire necessary skills through in-house training for Claim Examiner II position. Achieve Level II position within 36 months from start of Claims Examiner I.</li></ul></div><div><ul><li>
When necessary, refers inquiries to management, dental consultants or appropriate outside organizations.</li></ul></div><div><ul><li>
Provides management with required production figures as requested.</li></ul></div><div><ul><li>
Other duties as assigned</li></ul></div><div></div><div><b><br>
Essential Qualifications</b></div><div></div><div><b><br>
Competencies</b></div><div></div><div><div><div><br>
Adaptability-Flexibility</div><div><br>
Communication Skills</div></div><div><div><br>
Computer Skills</div><div><br>
Customer Focus</div></div><div><div><br>
Dependability</div><div><br>
Job Knowledge</div></div><div><div><br>
Productivity</div><div><br>
Quality</div></div><div><div><br>
Teamwork</div></div></div><div></div><div><b><br>
Technical and Functional</b></div><ul><li>
Personal computer skills with the ability to type 25 words per minute</li><li>
Possess the ability to use Microsoft Word and Excel</li><li>
Excellent written and oral communication skills</li><li>
Ability to research and troubleshoot problems</li><li>
Demonstrate good analytical and proofreading skills</li><li>
Attention to detail</li><li>
Good organizational skills</li></ul><div><b>
Key Performance Indicators</b></div><ul><li>
Meet-exceed CPH of 30 or above</li><li>
Maintain TQM of 99% or higher</li></ul><div><b>
Required Physical Abilities</b></div><div>
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.</div><br>
<div></div><ul><li>
Ability to sit and perform extensive close keyboard and PC work</li><li>
Ability to walk, talk or hear</li><li>
Occasionally required to stand and reach with hands and arms</li></ul><div><b>
Working Environment</b></div><ul><li>
Ability to meet deadlines and attendance standards.</li><li>
The noise level in the work environment is usually moderate.</li><li>
This classification will be required to sign a confidentiality agreement.</li></ul><div></div><div><b><br>
Experience, Education and Certifications Required</b></div><div></div><div><b><br>
Experience Required</b></div><ul><li>
1-3 years claims processing or related service experience</li><li>
Dental Assistant education/experience preferred</li></ul><div><b>
Required Educational Level</b></div><div><ul><li>
Requires high school diploma or equivalent.</li></ul></div></div>

Claims Examiner

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6680 claims examiner ii jobs Near Me

Claims Examiner II- MSI

Workers Compensation Claims Examiner II/III

Workers Compensation Claims Examiner II/III - Hybrid

Claims Supervisor - Workers Compensation

Workers Compensation Claims Examiner III

Workers Compensation Claims Examiner III

Claims Examiner