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claims specialist i

Blue Cross and Blue Shield of Louisiana

<p></p><div><p>We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with Blue Cross.</p><p></p><p>
Residency in or relocation to Louisiana is preferred for all positions.</p><p></p><div><b>
POSITION PURPOSE</b><p>
Duties may include the following responsibilities or functions required to support the claims unit. Accurate processing of claims edits, determining primacy for the Coordination of Benefits (COB), adjusting previously paid claims and initiating procedures to recover funds on overpaid claims. Accountable for complying with all laws and regulations that are associated with duties and responsibilities.</p></div><div><b>
NATURE AND SCOPE</b><ul><li>
This role does not manage people</li><li>
This role reports to this job: SUPERVISOR, CLAIMS OPERATIONS</li><li>
Necessary Contacts: In order to effectively fulfill this position, the Claims Specialist I must be in contact with personnel in other Units:<br>
<br>
Various internal departments and staff including, but not limited to, Provider Services, Legal, Internal Audit, IT, other Benefits Operations Management and staff, Enrollment and Billing, Administrative Services, and District Offices.<br>
<br>
Various external entities including, but not limited to, Providers, Members, Lawyers, Groups, Commissioner of Insurance, other insurance companies, and other Plans.</li></ul></div><div><b>
QUALIFICATIONS</b><br>
<br>
<b>Education</b><ul><li>
High School Diploma or equivalent required</li></ul><b>
Work Experience</b><ul><li>
6 months of experience in medical claims or health insurance-related customer service or the successful completion of BCBSLA adjustment or COB training</li></ul><b>
Skills and Abilities</b><ul><li>
Strong analytical ability, oral and written communication skills and human relations skills are necessary.<br>
</li><li>
Working knowledge of relevant PC software.<br>
</li></ul><b>
Licenses and Certifications</b><ul><li>
Certification in Medical Billing or Coding can be used in lieu of experience</li></ul></div><div><b>
ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS</b><ul><li>
Reviews, researches, and makes necessary updates to claims that may include the following: recalculation of benefits to previously processed claims, the processing of claims edits, or initiation of refund requests, according to contractual benefits or provider reimbursement rules, ultimately providing a high degree of customer satisfaction.<br>
</li><li>
Achieves and maintains a clear understanding of all systems, applications, and procedures necessary to identify denial codes, edits, and processing codes pertaining to all claims (including our coordination with additional coverage plans) in order to process both coordinated and non-coordinated claims correctly. Requesting of medical records may be required.<br>
</li><li>
Communicates, both orally and in writing, with internal and external contacts in order to provide necessary and accurate information for the establishment of sound claim records. This may include, but is not limited to, the coordination of benefits (COB), medical record requests, etc.<br>
</li><li>
Review quality audits for correction or routing within 48 hours of receipt following departmental and corporate guidelines to ensure accuracy of claims processing and customer satisfaction.<br>
</li><li>
Researches, investigates, and determines the correct order of benefits for payment to be made by the applicable plans and makes necessary corrections to COB records. Communicates to appropriate department(s) when Medicare has determined primacy incorrectly and ensures a letter is generated to notify Medicare. Failure to report discrepancy could result in a daily fine up to $1,000.00.<br>
</li><li>
Steps in and assists in any other capacity as deemed necessary (i.e., training, implementations, and documentation).<br>
</li></ul><b>
Additional Accountabilities and Essential Functions</b><br>
<i>The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions</i><ul><li>
Perform other job-related duties as assigned, within your scope of responsibilities.</li><li>
Job duties are performed in a normal and clean office environment with normal noise levels.</li><li>
Work is predominately done while standing or sitting.</li><li>
The ability to comprehend, document, calculate, visualize, and analyze are required.</li></ul></div><p></p><p><b>
An Equal Opportunity Employer</b></p><p></p><p><b>
All BCBSLA EMPLOYEES please apply through Workday Careers.</b></p><p>
PLEASE USE A WEB BROWSER OTHER THAN INTERNET EXPLORER IF YOU ENCOUNTER ISSUES (CHROME, FIREFOX, SAFARI)</p><p></p><p><b>
Additional Information</b></p><p>
Please be sure to monitor your email frequently for communications you may receive during the recruiting process. Due to the high volume of applications we receive, only those most qualified will be contacted. To monitor the status of your application, please visit the &quot;My Applications&quot; section in the Candidate Home section of your Workday account.
</p><p></p><p>If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact recruiting@bcbsla.com for assistance.</p><p></p><p>
In support of our mission to improve the health and lives of Louisianians, Blue Cross encourages the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free.</p><p></p><p><i>
Blue Cross and Blue Shield of Louisiana performs background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.
</i></p><p></p><p><i>Additionally, Blue Cross and Blue Shield of Louisiana is a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.</i></p></div>

Claims Specialist I

L.A. Care Health Plan

<div></div><div><div><div><div><div><div><div><p>Authorization Technician II
</p></div></div></div></div><div><div><div><div><b>Job Category: </b>Clinical
</div></div></div></div><div><div><div><div><b>Department: </b>Utilization Management
</div></div></div></div><div><div><div><div><b>Location:
</b>Los Angeles, CA, US, 90017
</div></div></div></div><div><div><div><div><b>Position Type: </b>Full Time
</div></div></div></div><div><div><div><div><b>Requisition ID: </b>13058
</div></div></div></div><div><div><div><div><div><b>Salary Range:</b> $47,840.00 (Min.) - $57,062.00 (Mid.) - $68,474.00 (Max.)</div><br>
<div></div>
<div>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation&rsquo;s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br>
<br>
Mission: L.A. Care&rsquo;s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br>
</div><div><div><div><div>Job Summary</div>
</div><div><div>
The Authorization Technician II supports the Utilization Management (UM) Specialist by handling all administrative and technical functions of the authorization process including intake, logging, tracking and status follow-up.</div><br>
<div></div>
<div>The Authorization Technician II collects information required by clinical staff to render decisions, assists the Manager and Director of the Utilization Management department in meeting regulatory time lines by maintaining an accurate database inventory of referral authorizations, retrospective reviews, concurrent reviews and grievance/appeal requests, and prepares UM Activity and Weekly Compliance Reports.</div><br>
<div></div>
<div>In addition, the position performs data entry and processing of referrals/authorizations in the system, authorizes request consistent with auto authorization criteria, maintains confidentiality when communicating member information, and assists with the communication of determinations by preparing template letters for members/ providers, with other duties as assigned.</div>
</div></div><div><div><div>
Duties</div>
</div><div><div>Functional Elements: Technical Support to UM Specialist: Processing of time sensitive authorization and pre-certification requests to meet department timeframes and regulatory requirements; Computer Input: Accurately and completely processing referrals/authorizations and distribute a complete file to UM Specialist within 2 hours of receipt; identify duplicate requests using the claims and verify existing authorization. Independently identifying and appropriately returning to claims or member services any file that is a duplicate to one already processed in the system; appropriately documenting what information was used in making this determination within 4 hours of receipt. Appropriate identification and timely notification of time sensitive requests; appropriately identifying for the staff which you support, request that are priority based on date of receipt and established Turnaround Time criteria for compliance. Accurate filing/maintenance of confidential member information. Creating secure, complete, files. Interface with members, medical personnel and other internal and external agencies; ensure all comply with L.A. Care requirements such as submitting requested information in a timely manner and using the approved Authorization Request form with complete medical information i.e.: ICD 10 codes, CPT, HCPC codes. (35%)</div>
<div></div><div>Assist in the preparation of communication for authorization determinations, including, but not limited to preparing template letters for members and providers (authorization approval, denial, deferral, modification and pay/education). (30%)</div>
<div></div><div>Assist in the technical aspects of the retrospective review process for authorizations and Member or Provider Appeals, including, but not limited to computer data entry, logging, copying, preparing of template letters for communication of appeal determinations to members, providers and partners (appeal uphold or overturn) and filing: Set up GNA files for review, log and keep track all due dates for each file. Inform nurses of a new case received from Grievance and Appeals Specialist.; submit all Grievances and Appeals response letters to Grievances Specialist on daily basis. (20%)</div>
<div></div><div>Support UM Committee and Audit activity via Department performance reporting. Assure the accuracy of reports concerning inventory and department proficiency in maintaining regulatory standards and time frames. (5%)</div>
<div>Perform other duties as assigned. (10%)</div>
</div></div><div><div><div>
Duties Continued</div>
</div></div><div></div><div><div><div>Education Required</div>
</div><div><div>High School Diploma/or High School Equivalency Certificate</div></div></div><div><div><div>
Education Preferred</div>
</div></div><div></div><div><div><div>Experience</div>
</div><div><div><b>
Required:</b></div>
<p>At least 6 months of health care experience.</p><br>
<p></p>
<p>Experience working in a cross functional work environment.</p><br>
<p></p>
<p><b>Preferred:</b></p>
<p>Experience in Medi-Cal managed care.</p><br>
<p></p>
<p>1 year of experience in UM/Prior Authorization.</p>
</div></div><div><div><div>
Skills</div>
</div><div><div><b>
Required:</b></div>
<p>Demonstrated proficiency in Medical Terminology required.</p><br>
<p></p>
<p>Strong verbal and written office communication skills.</p><br>
<p></p>
<p>Proficient with Microsoft Office Suite and Adobe PDF. and</p><br>
<p></p><p>Excellent organizational, interpersonal and time management skills.</p><br>
<p></p><p>Must be detail-oriented and an enthusiastic team player.</p><br>
<div></div>
<div><b>Preferred:</b></div>
<p>Knowledge of QNXT computer systems a plus.</p><br>
<p></p>
<p>Knowledge of the UM patient referral process.</p><br>
<p></p>
<p>Knowledge of member&rsquo;s health plan eligibility.</p><br>
<p></p>
<p>Knowledge of member&rsquo;s benefits coverage.</p><br>
<p></p><p>Knowledge of Health Plan regulations.</p><br>
<p></p>
<p>Knowledge of HMO/UM functions.</p><br>
<p></p>
<p>Knowledge of ICD-10/CPT coding.</p><br>
<p></p><p>Proficient utilizing electronic medical records and documentation programs.</p>
</div></div><div><div><div>
Licenses/Certifications Required</div>
</div></div><div></div><div><div><div>Licenses/Certifications Preferred</div>
</div><div><div>Medical Coding Certification</div></div></div><div><div><div>
Required Training</div>
</div></div><div></div><div><div><div>Physical Requirements</div>
</div><div><div>Light</div></div></div><div><div><div>
Additional Information</div>
</div><div><div><b>
Required:</b></div>
<div>Weekends and holidays hours may be required, as well as OT based on a business need.</div>
</div></div></div><div><b>
Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.</div><br>
<div></div>
<div><b>L.A. Care offers a wide range of benefits including</b></div>
<ul><li>Paid Time Off (PTO)</li>
<li>Tuition Reimbursement</li>
<li>Retirement Plans</li>
<li>Medical, Dental and Vision</li>
<li>Wellness Program</li>
<li>Volunteer Time Off (VTO)</li></ul><div><br>
</div></div></div></div></div><p><br>
<b>Nearest Major Market: </b>Los Angeles
<br>
<b>Job Segment: </b>EMR, Claims, Data Entry, Medical Coding, Healthcare, Insurance, Administrative</p></div></div></div><div></div>

Authorization Technician II

Exodus Recovery Inc.

<p><b>Job Summary:</b></p><p><b>Exodus Recovery, Inc (Exodus)</b> is looking to hire a <i>per diem </i><b>Private Insurance Coordinator.</b></p><p>Private Insurance Biller will provide support to Data Supervisor, Senior Data Specialist, Program Director, clinical staff and Executive team as a lead biller. Execute private insurance for all Exodus Recovery programs. Private Insurance Biller will maintain current data, train staff to read eligibility types, balance bill for PI clients, submit claims, track and follow up with insurance companies, train other billers to accurately bill and collect PI payments, adjudicate claims, travel to other counties to attend county trainings and work with local billing staff. Private Insurance Biller will provide status reports to the Executive Analyst and billing supervisor on current status of all PI claims and payments. Update all information using internal database created in conjunction with the data analyst team. Work as a lead for all reporting and conduct follow up related to private insurance. Heavy follow up, extensive hours on the phone with insurance companies, continued education, and professional development mandatory; stay current and informed of state and federal healthcare changes that apply to billing and HIPAA rules and regulations. This position will be required to travel to other counties and programs on a regular and as needed basis.</p><p><b>PLEASE NOTE: this is an in-office position requiring travel throughout Los Angeles County, and that work hours may vary</b></p><p><b>MINIMUM QUALIFICATIONS:</b></p><ul><li>Requirements: 2- 3 years&rsquo; experience in a customer service oriented position.</li><li>Experience with direct insurance billing for Mental Health Services, familiar with different types of healthcare plans. Strong administrative skills in a healthcare setting. Must be able to work independently without constant supervision. Must be able to travel and have own transportation, will work outside of LA County for different projects as needed.</li><li>Understanding of health insurance billing or claim process must be self-&shy; motivated, comfortable with spending many hours on calls with insurance companies. Must be able to travel regularly to other counties. Must be computer literate with a focus on Word documents, Excel spreadsheets, Speedy Claims and reports, Outlook and able to do Internet searches. Excellent communication and customer service skills are a must.</li></ul><p><b>EDUCATION:</b><br/>High School Diploma or GED. Bachelor&rsquo;s degree or equivalent work experience preferred.</p><p>Pay: $21.00 - $23.00 per hour</p><p>Benefits:</p><ul><li>401(k)</li><li>Employee assistance program</li></ul><p>Application Question(s):</p><ul><li>Do you have a familial or close relationship with a current Exodus employee? If yes, please tell us the employee&rsquo;s name.</li></ul><p>Ability to Commute:</p><ul><li>Los Angeles, CA 90056 (Required)</li></ul><p>Ability to Relocate:</p><ul><li>Los Angeles, CA 90056: Relocate before starting work (Required)</li></ul><p>Work Location: In person</p>

Private Insurance Coordinator

Capital Group

<div><p><b>&ldquo;I can be myself at work.&rdquo;</b></p><p></p><p>
You are more than a job title. We want you to feel comfortable doing great work and bringing your best, authentic self to everything you do. We value your talents, traditions, and uniqueness&mdash;and we&rsquo;re committed to fostering a strong sense of belonging in a respectful workplace.
</p><p></p><p>We intentionally seek diverse perspectives, experiences, and backgrounds, investing in a culture designed to celebrate differences. We believe that belonging leads to better outcomes and a stronger community of associates united by our mission. At Capital, we live our core values every day: Integrity, Client Focus, Diverse Perspectives, Long-Term Thinking, and Community.</p><p></p><p><b><br>
&ldquo;I can influence my income.&rdquo;</b></p><p></p><p><br>
You want to feel recognized at work. Your performance will be reviewed annually, and your compensation will be designed to motivate and reward the value that you provide. You&rsquo;ll receive a competitive salary, bonuses and benefits. Your company-funded retirement contribution will factor in salary and variable pay, including bonuses.</p><p></p><p><b><br>
&ldquo;I can lead a full life.&rdquo;</b></p><p></p><p><br>
You bring unique goals and interests to your job and your life. Whether you&rsquo;re raising a family, you&rsquo;re passionate about where you volunteer, or you want to explore different career paths, we&rsquo;ll give you the resources that can set you up for success.</p><ul><li><p>
Enjoy generous time-away and health benefits from day one, with the opportunity for flexible work options</p></li><li><p>
Receive 2-for-1 matching gifts for your charitable contributions and the opportunity to secure annual grants for the organizations you love</p></li><li><p>
Access on-demand professional development resources that allow you to hone existing skills and learn new ones</p></li></ul><p></p><p><b>
As a Data and Analytics Specialist </b>you will partner with business, data domain owners/stewards, and technology teams to define and deliver data products, analytics, and reporting that improve decision-making, strengthen data domain maturity, and measurably advance business outcomes.</p><p></p><p><b>
&ldquo;I am the person Capital Group is looking for.&rdquo;</b></p><p></p><ul><li><p>
I can define and drive a data product vision, strategy, and roadmap aligned to business priorities, value, and delivery feasibility.</p></li><li><p>
I can lead end-to-end data product lifecycle practices (intake, discovery, prioritization, delivery, adoption, measurement, and retirement).</p></li><li><p>
I can partner with data domain owners and stewards to assess current-state maturity, define target maturity, and execute a plan to close gaps.</p></li><li><p>
I can build strong partnerships with business units to understand decision needs and translate them into clear data and insight requirements.</p></li><li><p>
I can guide teams to collect, analyze, and interpret data to produce evidence-based recommendations and actionable insights.</p></li><li><p>
I can coach others in communicating complex findings through clear narratives and effective data visualizations for stakeholders.</p></li><li><p>
I can lead comprehensive data and business process analysis to solve complex problems across multiple stakeholders and capabilities.</p></li><li><p>
I can oversee the design, build, and maintenance of analytics and reporting solutions that enable scalable, trusted insights.</p></li><li><p>
I can stay current on emerging technologies, industry trends, and best practices and apply them to improve standards and delivery.</p></li><li><p>
I can champion data strategy and literacy by creating roadmaps, driving adoption and training plans, and tracking success metrics.</p></li><li><p>
I can lead and develop talent by setting goals, mentoring and coaching, managing performance, and supporting hiring efforts.</p></li><li><p>
I can lead with an AI-ready mindset, identifying opportunities to embed AI and automation into data products, workflows, and decision-making.</p></li></ul><p></p><p><b>
&ldquo;I can apply in less than 4 </b><b>minutes.&rdquo;</b></p><p><br>
</p><p>You&rsquo;ve reviewed this job posting and you&rsquo;re ready to start the candidate journey with us. Apply now to move to the next step in our recruiting process. If this role isn&rsquo;t what you&rsquo;re looking for, check out our other opportunities and join our talent community.</p><p><br>
</p><p><b>&ldquo;I can learn more about Capital Group.&rdquo;</b></p><p><br>
</p><p>At Capital Group, the success of the people who invest with us depends on the people in whom we invest. That&rsquo;s why we offer a culture, compensation and opportunities that empower our associates to build successful and prosperous careers. Through nine decades, our goal has been to improve people&rsquo;s lives through successful investing. We know that our history is a testament to the strength of the people we hire. More than 9,000 associates in 30+ offices around the world help our clients and each other grow and thrive every day. Find us on LinkedIn, Instagram, YouTube and Glassdoor.&lrm;</p><p></p>
Charlotte Base Salary Range: $153,842-$246,147<p>
&lrm;</p>
Southern California Base Salary Range: $179,273-$286,837<p>
&lrm;</p><p>
&lrm;</p><p>
&lrm;</p><p>
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In addition to a highly competitive base salary, per plan guidelines, restrictions and vesting requirements, you also will be eligible for an individual annual performance bonus, plus Capital&rsquo;s annual profitability bonus plus a retirement plan where Capital contributes 15% of your eligible earnings.</i></p><p></p><p><i>
You can learn more about our compensation and benefits </i><i>here</i><i>.</i></p><p></p><ul><li><i>Temporary positions in the United States are excluded from the above mentioned compensation and benefit plans.</i></li></ul><p><i><br>
We are an equal opportunity employer, which means we comply with all federal, state and local laws that prohibit discrimination when making all decisions about employment. As equal opportunity employers, our policies prohibit unlawful discrimination on the basis of race, religion, color, national origin, ancestry, sex (including gender and gender identity), pregnancy, childbirth and related medical conditions, age, physical or mental disability, medical condition, genetic information, marital status, sexual orientation, citizenship status, AIDS/HIV status, political activities or affiliations, military or veteran status, status as a victim of domestic violence, assault or stalking or any other characteristic protected by federal, state or local law.</i></p></div>

Data and Analytics Specialist

Ultimate Staffing

<div>
 <p>
  We are seeking an experienced Medical Claims Examiner to review, analyze, and adjudicate medical claims for accuracy, compliance, and medical necessity. The ideal candidate has strong working knowledge of
  <strong>
   ICD‑9 and ICD‑10 diagnosis coding
  </strong>
  and healthcare billing standards.
 </p>
 <p>
  <strong>
   Key Responsibilities:
  </strong>
 </p>
 <ul>
  <li>
   Review and process medical claims for completeness, accuracy, and compliance
  </li>
  <li>
   Apply ICD‑9 and ICD‑10 codes to evaluate claim validity
  </li>
  <li>
   Identify coding discrepancies, overpayments, and potential fraud or abuse
  </li>
  <li>
   Ensure claims adhere to payer policies, CMS guidelines, and regulatory requirements
  </li>
  <li>
   Document determinations and communicate findings as needed
  </li>
 </ul>
 <p>
  <strong>
   Qualifications:
  </strong>
 </p>
 <ul>
  <li>
   Proven experience as a Medical Claims Examiner or similar role
  </li>
  <li>
   Strong knowledge of
   <strong>
    ICD‑9 and ICD‑10 coding
   </strong>
  </li>
  <li>
   Familiarity with CPT, HCPCS, and medical billing guidelines
  </li>
  <li>
   Attention to detail and strong analytical skills
  </li>
  <li>
   Proficiency with claims processing systems and MS Office
  </li>
 </ul>
 <p>
  <strong>
   Preferred:
  </strong>
 </p>
 <ul>
  <li>
   CPC, CCS, or related certification
  </li>
  <li>
   Experience with Medicare, Medicaid, or commercial insurance claims
   <br/>
  </li>
 </ul>
 <p>
  <br/>
 </p>
 <strong>
  Desired Skills and Experience
  <br/>
  <br/>
 </strong>
 We are seeking an experienced Medical Claims Examiner to review, analyze, and adjudicate medical claims for accuracy, compliance, and medical necessity. The ideal candidate has strong working knowledge of ICD‑9 and ICD‑10 diagnosis coding and healthcare billing standards.
 <br/>
 Key Responsibilities:
 <br/>
 <br/>
 Review and process medical claims for completeness, accuracy, and compliance
 <br/>
 Apply ICD‑9 and ICD‑10 codes to evaluate claim validity
 <br/>
 Identify coding discrepancies, overpayments, and potential fraud or abuse
 <br/>
 Ensure claims adhere to payer policies, CMS guidelines, and regulatory requirements
 <br/>
 Document determinations and communicate findings as needed
 <br/>
 <br/>
 Qualifications:
 <br/>
 <br/>
 Proven experience as a Medical Claims Examiner or similar role
 <br/>
 Strong knowledge of ICD‑9 and ICD‑10 coding
 <br/>
 Familiarity with CPT, HCPCS, and medical billing guidelines
 <br/>
 Attention to detail and strong analytical skills
 <br/>
 Proficiency with claims processing systems and MS Office
 <br/>
 <br/>
 Preferred:
 <br/>
 <br/>
 CPC, CCS, or related certification
 <br/>
 Experience with Medicare, Medicaid, or commercial insurance claims
 <br/>
 <br/>
 <p>
  <em>
   All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, and Los Angeles County Fair Chance Ordinance.
  </em>
 </p>
</div>


Medical Claims Examiner

The Hanover Insurance Group

For more than 170 years, The Hanover has been committed to delivering on our promises and being there when it matters the most. We live our values every day, demonstrating we CARE through our values, Sustainability initiatives and inclusive corporate culture.
<br><br>
We are excited to announce a key role on our Large Loss Property team: Regional General Adjuster, Specialized Claims. This full time, exempt position offers remote flexibility and the opportunity to contribute to a collaborative, high performing group that manages some of our most significant claims.
<br><br>
This role covers the Northwest Territory. We are considering candidates who live in California, Washington, Oregon, Nevada, Utah, Colorado, or Idaho.
<br><br>
<b>Position Overview:</b> The Regional General Adjuster Specialized Claims is a senior-level claims position responsible for the full lifecycle management of highly complex and high-value commercial property claims. This includes the investigation, evaluation, negotiation, and resolution of claims that represent the company’s largest damage exposures and often involve intricate coverage issues.
<br>Claims handled in this role may originate from anywhere in the country and frequently require on-site field consultation and investigation. The position demands a high level of technical expertise, strategic thinking, and collaboration with internal and external stakeholders, including legal teams, engineers, and other subject matter experts.
<br><br>
<b>Responsibilities/Essential Functions:</b><br>
<ul>
<li>Independently lead investigations and manage the full lifecycle of highly complex, sensitive, and specialized claims.</li>
<li>Analyze coverage, damages, and financial exposure; develop tailored resolution strategies and negotiate high-value or contested claims.</li>
<li>Issue reservation of rights and draft coverage letters, including manuscript and ISO/non-ISO forms; interpret and apply commercial coverages and legal principles.</li>
<li>Set activities, reserves, and authorize payments within high authority limits.</li>
<li>Coordinate with internal and external experts (e.g., forensic analysts, underwriters, legal counsel, contractors) to ensure thorough evaluations and resolution.</li>
<li>Identify and pursue risk transfer opportunities; manage suspicious claims and refer to Special Investigation Unit as needed.</li>
<li>Serve as a subject matter expert (SME) for consistent handling of large losses; provide consultation on claim strategies and co-adjust files to support development.</li>
<li>Ensure compliance across jurisdictions including licensing, forms, deadlines, and accounting; maintain accurate and complete claim records.</li>
<li>Protect personally identifiable information (PII) and promote best practices across the team.</li>
<li>Represent the company in litigation, mediations, settlement conferences, and arbitrations; provide large loss and reinsurance reporting to underwriting.</li>
<li>Lead cross-functional meetings and collaborate with underwriting, agents, vendors, and legal teams to drive consensus and resolve claims.</li>
<li>Identify coverage gaps and partner with product management to enhance offerings.</li>
<li>Mentor and support less experienced adjusters; evaluate training programs and recommend improvements.</li>
<li>Lead quality initiatives to streamline workflows; use data tools to analyze trends and correct inconsistencies.</li>
<li>Maintain strong time and desk management skills; prepare reports and contribute to special projects.</li>
<li>Attend industry events and continuing education seminars to stay current on best practices.</li>
<li>Tailor communication strategies for specialized claims and maintain regular updates with leadership.</li>
<li>Build and maintain strong relationships with customers and stakeholders.</li>
</ul>
<b>Essential Skills and Experience:</b><br>
<ul>
<li>Bachelor’s degree preferred; equivalent experience accepted.</li>
<li>Typically requires 8+ years' experience handling complex large loss property claims</li>
<li>Extensive experience handling highly complex, high-value claims with significant legal, financial, and reputational exposure.</li>
<li>Recognized authority in negotiation and resolution of complex claims; able to shape best practices and influence outcomes.</li>
<li>Demonstrated expertise in analyzing policy coverage, legal liability, and regulatory frameworks across jurisdictions.</li>
<li>Represent the company in trials, mediations, and arbitrations.</li>
<li>Experience mentoring others and contributing to the development of investigative techniques, compliance protocols, and claims handling standards.</li>
<li>Strong written and verbal communication skills; able to simplify complex information and handle sensitive issues with professionalism.</li>
<li>Skilled in selecting appropriate communication channels and demonstrating empathy across diverse stakeholder groups.</li>
<li>Ability to draft clear, factual, and objective work product without opinion.</li>
<li>Highly organized with proven ability to manage complex workflows, projects, and competing priorities.</li>
<li>Demonstrated time management and organizational skills; able to coach others in these areas.</li>
<li>Deep understanding of insurance principles, coverage interpretation, and jurisdictional requirements.</li>
<li>Strategic thinker with sound judgment; able to make informed decisions independently and assess financial implications.</li>
<li>Expert in identifying and mitigating legal, regulatory, and reputational risks</li>
<li>Recognized for developing empathetic customer service strategies and delivering exceptional service.</li>
<li>Proficiency with Xactimate/ Xactanalysis and standard office software, including Microsoft Word and Microsoft Excel.</li>
</ul>
<b>Core Capabilities:</b><br>
<b>Analytical Reasoning:</b> The ability to identify problems, understand your impact, gather input and data, and develop an effective solution.
<br><b>Customer Centricity:</b> Makes customers/clients and their needs a primary focus of one’s actions; shows interest in and understanding of the needs and expectations of internal and external customers; gains customer trust and respect; meets or exceeds customer expectations.
<br><b>Digital Fluency:</b> Effectively uses digital tools and technology appropriately to find, evaluate, create, and communicate information understands how to navigate digital platforms, use software applications, and leverage technology for productivity and communication purposes.
<br><b>Persuasion and Influence:</b> Uses appropriate interpersonal skills and techniques to gain acceptance for ideas or solutions; uses influencing strategies to gain genuine agreements; seeks to persuade rather than force solutions or impose decisions or regulations.
<br><b>Professional Insurance Acumen:</b> Demonstrates a deepening understanding of the insurance industry and the ability to apply specialized technical skills to address complex challenges, adapt to industry trends, and drive value for the organization.
<br><b>Planning and Execution:</b> Plans, prioritizes and manages resources and time effectively to achieve specific goals or deadlines.
<br><br>
<b>Physical Demands and Work Environment:</b><br>
<ul>
<li>Ability to use a personal computer and other standard office equipment.</li>
<li>Ability to sit and/or stand for extended periods.</li>
<li>Required to work on-site as needed.</li>
<li>Ability to travel as necessary.</li>
<li>Ability to work in a fast-paced, changing or stressful environment.</li>
<li>Ability to perform work in a noisy/loud work environment.</li>
<li>May be required to have and maintain sufficient home-based internet connection</li>
<li>Ability to walk, stand, bend, kneel, and climb for extended periods during field inspections.</li>
<li>Ability to safely lift, carry and handle equipment weighing approximately 25-40 lbs.</li>
<li>Ability to work in adverse environmental conditions and within damaged or partially compromised structures.</li>
<li>Ability to access and inspect roofs using appropriate safety measures.</li>
</ul>
<b>CAREER DEVELOPMENT:</b><br>
It’s not just a job, it’s a career, and we are here to support you every step of the way. We want you to be successful and fulfilled. Through on-the-job experiences, personalized coaching and our robust learning and development programs, we encourage you – at every level – to grow and develop.
<br><br>
<b>BENEFITS:</b><br>
We offer comprehensive benefits to help you be healthy, build financial security, and balance work and home life. At The Hanover, you’ll enjoy what you do and have the support you need to succeed.
<br><br>
<b>Benefits include:</b><br>
<ul>
<li>Medical, dental, vision, life, and disability insurance</li>
<li>401K with a company match</li>
<li>Tuition reimbursement</li>
<li>PTO</li>
<li>Company paid holidays</li>
<li>Flexible work arrangements</li>
<li>Cultural Awareness Day in support of IDE</li>
<li>On-site medical/wellness center (Worcester only)</li>
<li>Click here for the full list of Benefits</li>
</ul>
<b>EEO statement:</b><br>
The Hanover values diversity in the workplace and among our customers. The company provides equal opportunity for employment and promotion to all qualified employees and applicants on the basis of experience, training, education, and ability to do the available work without regard to race, religion, color, age, sex/gender, sexual orientation, national origin, gender identity, disability, marital status, veteran status, genetic information, ancestry or any other status protected by law.
<br><br>
Furthermore, The Hanover Insurance Group is committed to providing an equal opportunity workplace that is free of discrimination and harassment based on national origin, race, color, religion, gender, ancestry, age, sexual orientation, gender identity, disability, marital status, veteran status, genetic information or any other status protected by law.”
<br><br>
As an equal opportunity employer, Hanover does not discriminate against qualified individuals with disabilities. Individuals with disabilities who wish to request a reasonable accommodation to participate in the job application or interview process, or to perform essential job functions, should contact us at: HRServices@hanover.com and include the link of the job posting in which you are interested.
<br><br>
<b>Privacy Policy:</b><br>
To view our privacy policy and online privacy statement, click here.
<br><br>
<b>Applicants who are California residents:</b> To see the types of information we may collect from applicants and employees and how we use it, please click here.
<br><br>
<b>Compensation:</b><br>
The target hiring range for this role may vary based on geographic location and other factors, including merit or performance, demonstrated proficiency, skills for the role, education, travel requirements, and experience. Additional compensation may include an annual bonus (which could take the form of a general bonus, sales incentive, or short-term incentive), long-term incentive or spot recognition awards. The posted range reflects our ability to hire at different position titles and levels depending on background and experience.

Regional General Adjuster (Large Loss Commercial Property)

CVS Health

<div><p>We&rsquo;re building a world of health around every individual &mdash; shaping a more connected, convenient and compassionate health experience. At CVS Health&reg;, you&rsquo;ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger &ndash; helping to simplify health care one person, one family and one community at a time.</p><p></p><p><b>
Position Summary:</b><br>
This position is directly responsible for the supervision of our workers&rsquo; compensation claims program with a financial exposure for CVS. This involves the oversight of all workers&rsquo; compensation claims in an assigned territory that are handled by insurance carriers and Third-Party Administrators (TPA). This position is directly responsible for ensuring adherence to claim handling guidelines, analyzing TPA performance and directing claims handling. In addition, this position requires the ability to field and provide solutions on a high volume of inquiries from the CVS business units and departments.</p><p></p><p><b>
Responsibilities</b></p><ul><li>
Proactively oversee and manage TPA performance through reporting, auditing, and claim reviews.</li><li>
Oversee the daily work product of multiple lost time and medical-only workers&rsquo; compensation adjusters in your assigned territory, completing monthly audits and case reviews.</li><li>
Actively participate in internal claim reviews and legal roundtables.</li><li>
Ensure that reserves and settlement authorities are reviewed and granted in compliance with our internal processes.</li><li>
Review and interpret medical reports, expert reports, legal and various supporting claim documents.</li><li>
Analyze case and internal investigative materials to determine legal liability and that reserves are set for the known exposure.</li></ul><p></p><p><b>
Required Qualifications</b></p><ul><li>
1-3 years&rsquo; experience handling Lost Time workers&rsquo; compensation claims and/or equivalent experience with TPA oversight.</li><li>
Experience in Microsoft Office applications with a proven ability to learn new software programs and systems as required.</li></ul><p></p><h2 class="jobSectionHeader"><b>
Preferred Qualifications
</b></h2><ul><li>Insurance designations is a plus.</li><li>
California workers&rsquo; compensation claims handling experience or jurisdictional knowledge a plus.</li><li>
Ability to interact and navigate situations with both internal and external partners.</li><li>
Ability to work independently and in an environment requiring teamwork and collaboration.</li><li>
Ability to train less experienced TPA adjusters on implementation of claim best practices.</li><li>
Demonstrate excellent analytical, organizational, written, and communication skills, with the ability to generate concise claim outlines that capture and detail critical case components.</li><li>
Exhibit proven time management skills and the ability to oversee a high volume of cases effectively.</li></ul><h2 class="jobSectionHeader"><b>
Education</b></h2><ul><li>
High School Diploma or Equivalent</li></ul><p></p><p><b>
Anticipated Weekly Hours</b></p>
40<p></p><p><b>
Time Type</b></p>
Full time<p></p><p><b>
Pay Range</b></p><p>
The typical pay range for this role is:</p><p></p>
$43,888.00 - $102,081.00<p></p><p>
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.</p><p><br>
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.</p><p></p><p><b>
Great benefits for great people</b></p><p></p><p>
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.</p><br>
This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.<p><br>
Additional details about available benefits are provided during the application process and on Benefits Moments.</p><br>
We anticipate the application window for this opening will close on: 05/15/2026<p></p><p>
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</p></div>

Analyst, Risk Management – Workers’ Compensation

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