disability insurance claim examiner

Athens Administrators

<div>
 ATHENS POSITION DETAILS
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 <br/>
 <strong>
  Position Title:
  <br/>
  <br/>
 </strong>
 Assistant Claims Examiner - Flex
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 <strong>
  Department:
  <br/>
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 </strong>
 Workers&rsquo; Compensation
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 <strong>
  Reports To:
  <br/>
  <br/>
 </strong>
 Claims Supervisor
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 <strong>
  FLSA Status:
  <br/>
  <br/>
 </strong>
 Non-Exempt
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 <strong>
  Job Grade:
  <br/>
  <br/>
 </strong>
 6
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 <strong>
  Career Ladder:
  <br/>
  <br/>
 </strong>
 Next step in progression could include Future Medical Examiner or Claims Examiner Trainee
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 <strong>
  ATHENS ADMINISTRATORS
  <br/>
  <br/>
 </strong>
 Explore the Athens Administrators difference: We have been dynamic, innovative leaders in claims administration since our founding in 1976. We foster an environment where employees not only thrive but consistently recognize Athens as a &ldquo;Best Place to Work.&rdquo; Immerse yourself in our engaging, supportive, and inclusive culture, offering opportunities for continuous professional growth. Join our nationwide family-owned company in Workers' Compensation, Property &amp; Casualty, Program Business, and Managed Care. Embrace a change and come make an impact with the Athens Administrators family today!
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 <strong>
  Position Summary
  <br/>
  <br/>
 </strong>
 Athens Administrators has an immediate need for an experienced Assistant Claims Examiner - Flex to support our Workers&rsquo; Compensation department and can be located anywhere in the state of California, however, employees who live less than 26 miles from the Concord, CA or Orange, CA offices are required to work once a week in the office on a day determined by their supervisor between Tuesday &ndash; Thursday. The remaining days can be worked remotely if technical requirements are met, and the employee resides in California. Athens offices are open for business Monday-Friday from 7:30 a.m. to 5:30 p.m. local time. The schedule for this position is Monday-Friday at 37.5 hours a week with the option of a flex schedule.
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 The Assistant Claims Examiner - Flex will provide clerical and technical assistance to Senior Claims Examiners and administer Medical Only claims, ensuring timely processing of claims and payment of benefits, managing, and directing medical treatment, and setting reserves for a variety of teams and clients at Athens.
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 <strong>
  Primary Responsibilities
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  <br/>
 </strong>
 Our new hire should have the skills, ability, and judgment to perform the following essential job duties and responsibilities with or without reasonable accommodation. Additional duties may be assigned:
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 <ul>
  <li>
   Process new claims in compliance with client&rsquo;s Service Agreement
  </li>
  <li>
   Issue all indemnity payments and awards on time
  </li>
  <li>
   Process all approved provider bills timely
  </li>
  <li>
   Prepare objection letters to providers for medical bills; delayed, denied, lacking reports.
  </li>
  <li>
   Answer questions over the phone from medical providers regarding bills
  </li>
  <li>
   Contact treating physician for disability status
  </li>
  <li>
   Contact employer for return-to-work status or availability of modified work.
  </li>
  <li>
   Contact injured worker at initial set up
  </li>
  <li>
   Send DWC notices timely
  </li>
  <li>
   Issue SJDB Notices timely
  </li>
  <li>
   Request Job Description from Employer
  </li>
  <li>
   Handle Medical Only claim files
  </li>
  <li>
   Calculate wage statements and adjust disability rates as required
  </li>
  <li>
   Keep diary for all delay dates and indemnity payments
  </li>
  <li>
   Documents file activity on computer
  </li>
  <li>
   Update information on computer, i.e., address changes, etc.
  </li>
  <li>
   Schedule appointments for AME, QME evaluations
  </li>
  <li>
   Send appointment letters, issue TD/mileage, send medical file
  </li>
  <li>
   Schedule interpreter for appointments, depositions, etc.
  </li>
  <li>
   Request Employer&rsquo;s Report, DWC-1, Doctor&rsquo;s First Report if needed
  </li>
  <li>
   Verify mileage and dates of treatment for reimbursement to claimant
  </li>
  <li>
   Subpoena records
  </li>
  <li>
   File and serve documents on attorneys, WCAB, doctors
  </li>
  <li>
   Serve PTP&rsquo;s with medical file and Duties of Treating Physician (9785)
  </li>
  <li>
   Request PD ratings from DEU
  </li>
  <li>
   Draft Stipulated Awards and C&amp;R&rsquo;s
  </li>
  <li>
   Submit C&amp;R, Stipulated Awards to WCAB for approval with documentation
  </li>
  <li>
   Process checks &ndash; stop payment, cancellations, void, journal payments
  </li>
  <li>
   Handle telephone calls for examiner as needed
  </li>
  <li>
   Complete penalty calculations and prepare penalty worksheets
  </li>
  <li>
   Complete MPN, HCO and/or EDI coding
  </li>
  <li>
   Complete referrals to investigators
  </li>
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   Complete preparation of documents for overnight delivery
  </li>
  <li>
   Work collaboratively with Senior Claims Examiners, Nurse Case Managers, and other Assistant Claims Examiners
  </li>
  <li>
   Contact with clients, injured workers, attorneys, doctors, vendors, and other parties
  </li>
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   Provide updates of claims status to Senior Claims Examiners and Athens management
  </li>
  <li>
   Prepare professional, well written correspondence and other communications
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   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Essential Position Requirements
  <br/>
  <br/>
 </strong>
 The requirements listed below are representative of the knowledge, skill, and/or ability required. While it does not encompass all job requirements, it is meant to give you a solid understanding of expectations.
 <br/>
 <br/>
 <ul>
  <li>
   High School Diploma or equivalent (GED) required for all positions
  </li>
  <ul>
   <li>
    AA/AS or BA/BS preferred but not required
   </li>
  </ul>
  <li>
   2+ years&rsquo; Claims Assistant experience supporting a workers compensation examiner or team preferred
  </li>
  <li>
   Medical Only Adjuster designation required
  </li>
  <li>
   Continuing hours must be current
  </li>
  <li>
   Mathematical calculating skills
  </li>
  <li>
   Completion of IEA or equivalent courses
  </li>
  <li>
   Administrators Certificate from Self-Insurance Plans preferred
  </li>
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   Knowledge of workers compensation laws, policies, and procedures
  </li>
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   Understanding of medical and legal terminology
  </li>
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   Must demonstrate accuracy and thoroughness in work product
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   Ability to sit for prolonged periods of time
  </li>
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   Well-developed verbal and written communication skills with strong attention to detail
  </li>
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   Excellent organizational skills and ability to multi-task
  </li>
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   Ability to type quickly, accurately and for prolonged periods
  </li>
  <li>
   Proficient in Microsoft Office Suite
  </li>
  <li>
   Ability to learn additional computer programs
  </li>
  <li>
   Reasoning ability, including problem-solving and analytical skills, i.e., proven ability to research and analyze facts, identify issues, and make appropriate recommendations and solutions for resolution
  </li>
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   Ability to be trustworthy, dependable, and team-oriented for fellow employees and the organization
  </li>
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   Seeks to include innovative strategies and methods to provide a high level of commitment to service and results
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   Ability to demonstrate care and concern for fellow team members and clients in a professional and friendly manner
  </li>
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   Acts with integrity in difficult or challenging situations and is a trustworthy, dependable contributor
  </li>
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   Athens&rsquo; operations involve handling confidential, proprietary, and highly sensitive information, such as health records, client financials, and other personal data. Therefore, maintaining honesty and integrity is essential for all roles within the company.
  </li>
  <li>
   Must be able to reliably commute to meetings and events as required by this position
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  APPLY WITH US
  <br/>
  <br/>
 </strong>
 We look forward to learning about YOU! If you believe in our core values of honesty and integrity, a commitment to service and results, and a caring family culture, we invite you to apply with us. Please submit your resume and application directly through our website at http://www.athensadmin.com/careers/job-openings Feel free to include a cover letter if you&rsquo;d like to share any other details. All applications received are reviewed by our in-house Corporate Recruitment team. The Company will consider qualified applicants with arrest or conviction records in accordance with the Los Angeles Fair Chance Ordinance for Employers and the California Fair Chance Act. Applicants can learn more about the Los Angeles County Fair Chance Act, including their rights, by clicking on the following link: https://dcba.lacounty.gov/wp-content/uploads/2024/08/FCOE-Official-Notice-Eng-Final-8.30.2024.pdf
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 <br/>
 This description portrays in general terms the type and levels of work performed and is not intended to be all-inclusive or represent specific duties of any one incumbent. The knowledge, skills, and abilities may be acquired through a combination of formal schooling, self-education, prior experience, or on-the-job training.
 <br/>
 <br/>
 Athens Administrators is an Equal Opportunity/ Affirmative Action employer. We provide equal employment opportunities to all qualified employees and applicants for employment without regard to race, religion, sex, age, marital status, national origin, sexual orientation, citizenship status, veteran status, disability, or any other legally protected status. We prohibit discrimination in decisions concerning recruitment, hiring, compensation, benefits, training, termination, promotions, or any other condition of employment or career development.
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 <strong>
  THANK YOU!
  <br/>
  <br/>
 </strong>
 We look forward to reviewing your information. We understand that applying for jobs may not be the most enjoyable task, so we genuinely appreciate the time you've dedicated. Don&rsquo;t forget to check out our website at www.athensadmin.com as well as our LinkedIn, Glassdoor, and Facebook pages!
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 Athens Administrators is dedicated to fair and equitable compensation for our employees that is both competitive and reflective of the market. The estimated rate of pay can vary depending on skills, knowledge, abilities, location, labor market trends, experience, education including applicable licenses &amp; certifications, etc. Our ranges may be modified at any time. In addition, eligible employees may be considered annually for discretionary salary adjustments and/or incentive payments. We offer a variety of benefit plans including Medical, Vision, Dental, Life and AD&amp;D, Long Term Care, Critical Care, Accidental, Hospital Indemnity, HSA &amp; FSA options, 401k (and Roth), Company-Paid STD &amp; LTD and more! Further information about our comprehensive benefits package may be found on our website at
 <strong>
  https://www.athensadmin.com/careers/why-work-here
 </strong>
</div>


Assistant Claims Examiner - Remote or Hybrid in CA

State of Tennessee

<div><p><b>Job Information</b>
</p><h3 class="jobSectionHeader"><b>State of Tennessee Job Information</b></h3><p><div><div><div>
Opening Date/Time</div><div> 05/05/2026 12:00AM Central Time</div></div><br>
<div><div>
Closing Date/Time</div><div> 05/18/2026 11:59PM Central Time</div></div><br>
<div><div>
Salary (Monthly)</div><div> $3,631.00 - $4,533.00</div></div><br>
<div><div>
Salary (Annually)</div><div> $43,572.00 - $54,396.00</div></div><br>
<div><div>
Job Type</div><div> Full-Time</div></div><br>
<div><div>
City, State Location</div><div> Nashville, TN</div></div><br>
<div><div>
Department</div><div> Human Services</div></div></div></p><p><b><br>
LOCATION OF (4) POSITION(S) TO BE FILLED: DEPARTMENT OF HUMAN SERVICES, DAVIDSON COUNTY</b><br>
<br>
<b>For more information, visit the link below:</b></p><p><b>
https://www.tn.gov/content/dam/tn/human-services/documents/HRC0019759_DISABILITY_CLAIMS_EXAMR1_Davidson_51826.pdf</b><br>
<br>
<b>This is a remote position</b><br>
<br>
<b>This position requires a criminal background check. Therefore, you may be required to provide information about your criminal history in order to be considered for this position.</b></p><p><b>
Qualifications</b>
</p><p><b>Education and Experience:</b> Graduation from an accredited college or university with a bachelor's degree.</p><p><b>
Substitution of Experience for Education:</b> Full-time professional disability claims examination work may be substituted for the required education on a year-for-year basis.</p><p><b>
Necessary Special Qualifications:</b></p><ul><li>
Complete a federal background check in accordance with the Homeland Security Presidential Directive 12 (HSPD-12) for issuance of an HSPD-12 compliant Personal Identity Verification (PIV) credential card.</li><li>
After appointment, successfully complete (as indicated by an assessment at completion) a prescribed course of training offered by the Tennessee Department of Human Services.</li></ul><p><b>
Overview</b>
</p><p>This classification learns to perform disability determination work of average difficulty. An employee in this class is responsible for learning to determine adult medical eligibility for Social Security Disability, Supplemental Security Income or Medicaid benefits for initial claims in accordance with federal Social Security Administration guidelines. This classification performs responsibilities under direct supervision at the learning level. This class differs from the Disability Claims Examiner 2 in that an incumbent of the latter functions at the working level.</p><ul><li><i>An applicant appointed to this classification will be reclassified to a Disability Claims Examiner 2 after successful completion of a mandatory two-year training period; 'unacceptable' or 'needs improvement' performance ratings during the training period will result in automatic demotion or termination.</i></li></ul><p><b>
Responsibilities</b>
</p><p>ALL LISTED RESPONSIBILITIES WILL BE PERFORMED AT THE LEARNING LEVEL:</p><ul><li>
Determines adult medical eligibility for Social Security Disability, Supplemental Security Income or Medicaid benefits using medical, psychiatric, vocational, and educational data for initial claims in accordance with federal Social Security Administration guidelines.</li><li>
Routinely conducts telephone interviews with claimants and others to obtain and/or clarify information on applications. Determines jurisdiction and proper timeframe for requests of claimant records and obtains records from relevant treatment sources.</li><li>
Reviews and analyzes applications, medical assessments, medical records, and vocational assessments as needed for initial claims. Reviews prior decisions for accuracy and development of evidence and examines new allegations or evidence, redetermines medical eligibility, and issues reconsideration decisions.
</li><li>Documents case notes, appointments, and general correspondence for review and adjudication. Organizes and enters claimant documentary evidence and claim decisions into an electronic case management folder.</li><li>
Assesses claimant's medical conditions to identify impairments, onset issues, and limitations by reviewing medical records, statements, and other pertinent information to prepare a medical assessment.
</li><li>Confers with internal medical consultants and various other subject matter experts to ensure all aspects of disability claims are in accordance with federal guidelines. Selects, composes, and sends proper federal disability determination notices to claimants explaining medical and vocational decision issues to claimants and authorized representatives.</li><li>
Schedules/reschedules consultative examination appointments for claimants and notify claimants, third parties, attorneys of appointment time and date, and documents reasons for missed exams. Authorizes payments for examinations and claimant travel.</li><li>
Reviews claimant's work history to determine if claimant's past work description is adequate and contacts claimant by phone if additional work history is needed. Identifies and analyzes claimant's past relevant work by researching jobs and earnings reported to SSA and compare the claimant's residual capacity with the functional requirements of the claimant's past and other work.</li></ul><p><b>
Competencies (KSA's)</b>
</p><p><b>Competencies:</b></p><ul><li>
Customer Focus</li><li>
Resourcefulness</li><li>
Communicates Effectively</li><li>
Instills Trust</li><li>
Situational Adaptability</li></ul><p><b>
Knowledges:</b></p><ul><li>
Customer and Personal Service</li></ul><p><b>
Skills:</b></p><ul><li>
Active Learning and Listening</li><li>
Service Orientation</li><li>
Critical Thinking</li><li>
Judgment and Decision Making</li><li>
Time Management</li></ul><p><b>
Abilities:</b></p><ul><li>
Deductive Reasoning</li><li>
Inductive Reasoning</li><li>
Problem Sensitivity</li><li>
Written Comprehension</li></ul><p><b>
Tools &amp; Equipment</b>
</p><ul><li>General Office Equipment</li><li>
Computer/Laptop/Tablet</li><li>
Multifunction Printer (Print/Copy/Scan/Fax)</li><li>
Cell Phone</li></ul></div>

DISABILITY CLAIMS EXAMINER 1* - 05052026-77330

Prudential

<div><p>Job Classification:</p>
Operations - Insurance Operations<p></p><p><b>
Operations - Insurance Operations</b></p><p></p><p>
We are seeking a Senior Claim Manager to provide top-tier customer service for a dedicated Group Insurance National Account client. In this role, you will gain a deep understanding of the clients&rsquo; culture. You will apply your expert customer service skills to guide and support their employees at the start of their leave and throughout the life cycle of the claim. To ensure a seamless experience for employees, you will work with various products, including Short Term Disability, Absence, Statutory Leaves and Long Term Disability.</p><p></p><p><b>
Responsibilities:</b></p><ul><li>
Achieve team and individual goals, leverage resources and collaborate with colleagues by sharing best practices and technical direction across 1:1, small group, and team settings.</li><li>
Become thoroughly familiar with the clients&rsquo; culture and product offerings to deliver exceptional service to both the client and their employees.</li><li>
Enhance the claimants&rsquo; experience and act as a champion for continuous process improvement.</li></ul><p></p><p><b>
Qualifications:</b></p><ul><li>
Experience in STD and LTD, FMLA, and/or State Leave adjudication.</li><li>
Highly effective in delivering proactive communication across a range of channels, including phone, email, letters, Teams messaging, group Teams calls, and one-on-one video calls, to support an exceptional customer experience.</li><li>
Customer-focused, with a proven ability to create and maintain strong customer relationships.</li><li>
Skilled and confident in communicating difficult messages.</li><li>
Excellent documentation skills to accurately capture telephone conversations, create clear, concise claim plans, and write detailed decision letters.</li><li>
Ability to understand and interpret complex and non-standard policy and plan provisions.</li><li>
Strong ability to independently navigate ambiguous situations and adapt quickly when needed.</li><li>
Excellent organizational and time management skills.</li></ul><p></p><p><b>
Work Environment:</b></p><p></p><p>
Occasional travel to an office location may be required.</p><p></p><h2 class="jobSectionHeader"><b>
#LI-MG1</b></h2><p></p><h1 class="jobSectionHeader"><b>
What we offer you:</b></h1><p></p>
Prudential is required by state specific laws to include the salary range for this role when hiring a resident in applicable locations. The salary range for this role is from $61,700.00 to $101,900.00. Specific pricing for the role may vary within the above range based on many factors including geographic location, candidate experience, and skills.<ul><li><p><b>
Market competitive base salaries, with a yearly bonus potential at every level</b><b>.</b></p></li><li><p><b>
Medical, dental, vision, life insurance, disability insurance, Paid Time Off (PTO), and leave of absences, such as parental and military leave</b><b>.</b></p></li><li><p>
401(k) plan with company match (up to 4%).</p></li><li><p>
Company-funded pension plan.</p></li><li><p><b>
Wellness Programs</b><b> </b>including up to $1,600 a year for reimbursement of items purchased to support personal wellbeing needs.</p></li><li><p><b>
Work/Life Resources</b> to help support topics such as parenting, housing, senior care, finances, pets, legal matters, education, emotional and mental health, and career development.</p></li><li><p><b>
Education Benefit</b> to help finance traditional college enrollment toward obtaining an approved degree and many accredited certificate programs.</p></li><li><p><b>
Employee Stock Purchase Plan: </b><b>Shares</b> can be purchased at 85% of the lower of two prices (Beginning or End of the purchase period), after one year of service.</p></li></ul><p></p><p>
Eligibility to participate in a discretionary annual incentive program is subject to the rules governing the program, whereby an award, if any, depends on various factors including, without limitation, individual and organizational performance. To find out more about our Total Rewards package, visit Work Life Balance | Prudential Careers. Some of the above benefits may not apply to part-time employees scheduled to work less than 20 hours per week.</p><p></p><div><p>
Prudential Financial, Inc. of the United States is not affiliated with Prudential plc. which is headquartered in the United Kingdom.</p></div><p></p><div><p>
Prudential is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, national origin, ancestry, sex, sexual orientation, gender identity, national origin, genetics, disability, marital status, age, veteran status, domestic partner status, medical condition or any other characteristic protected by law.</p></div><p></p><div><p>
If you need an accommodation to complete the application process, please email accommodations.hw@prudential.com.</p></div><p></p><div><p><br>
If you are experiencing a technical issue with your application or an assessment, please email careers.technicalsupport@prudential.com to request assistance.</p></div></div>

Senior Disability Claims Examiner, National Accounts Claim Team

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

ELITE

<div><b>POSITION DETAILS</b><br>
<div><div><div><div><b>Position Title:</b></div> <div>Senior Claims Examiner</div>
</div><br>
<div><div><b>Department:</b></div> <div>Workers&rsquo; Compensation California</div>
</div><br>
<div><div><b>Reports To:</b></div> <div>Claims Supervisor</div>
</div><br>
</div></div><br>
<b>POSITION SUMMARY</b><br>
COMPANY has an immediate need for a Senior Claims Examiner to support our workers compensation offices and can be located anywhere in the state of California. The schedule for this position is Monday-Friday at 37.5 hours a week.<br>
<br>
The Senior Claims Examiner will adjust workers&rsquo; compensation claims from inception through settlement and closure, ensuring timely processing of claims and payment of benefits, managing, and directing medical treatment, setting reserves, and negotiating settlements. The Senior Claims Examiner will adjust workers&rsquo; compensation claims from inception through settlement and closure, ensuring timely processing of claims and payment of benefits, managing, and directing medical treatment, setting reserves, and negotiating settlements.<br>
<br>
<b>PRIMARY RESPONSIBILITIES</b><br>
Our new hire should have the skills, ability, and judgment to perform the following essential job duties and responsibilities with or without reasonable accommodation. Additional duties may be assigned:<br>
<ul><li>Establish contact with employer to review issues</li>
<li>Respond to inquiries from the employer, employee, doctors, and attorneys</li>
<li>Establish and maintain appropriate reserves</li>
<li>Review legal correspondence and medical reports</li>
<li>Evaluate and approve medical procedures and treatment</li>
<li>Administer benefits and ensure appropriateness of all payments</li>
<li>Investigate coverage, liability, and monetary value of claim</li>
<li>Review medical and legal bills for appropriateness</li>
<li>Discuss appropriateness of medical treatment with medical case manager</li>
<li>Determine compensability</li>
<li>Monitor and assist litigation</li>
<li>Negotiate settlement of claim, liens, rehabilitation plans, etc.</li>
<li>Prepare and present reports to clients</li>
<li>Appropriately close claims</li>
<li>Help resolve client billing and payment inquiries
</li><li>Investigate complaints from injured workers</li>
<li>Document and code the claim files and claims system with all relevant information</li>
<li>Maintain and update action plans within specified time frames</li>
<li>Provide direction to Claims Assistants and Claims Technicians and assist with training, coaching, and mentoring as needed for them to support daily claims tasks</li>
<li>Contact with employers, employees, attorneys, doctors, vendors, and other parties</li>
<li>Provide customer service and support to clients and claimants</li>
<li>Work collaboratively with attorneys to draft settlements and assist with litigation strategies</li>
<li>Negotiate settlements</li>
<li>Authorize and negotiate cost of medical treatment and supplies</li>
<li>Internal communication with staff</li>
<li>Prepare professional, well written correspondence and other communications</li>
</ul>
<br>
<b>ESSENTIAL POSITION REQUIREMENTS
</b><br>
The requirements listed below are representative of the knowledge, skill, and/or ability required. While it does not encompass all job requirements, it is meant to give you a solid understanding of expectations.<br>
<ul><li>High School Diploma or equivalent (GED) required for all positions
<ul><li>AA/AS or BA/BS preferred but not required</li>
</ul></li><li>Administrators Certificate from Self-Insurance Plans will be required within one year of employment if not already obtained</li>
<li>Must possess a current Experienced Indemnity Claims Adjuster Designation, provided by an insurer, as defined in California Code of Regulations, Title 10, Chapter 5, Subchapter 3, Section 2592.01(f)</li>
<li>3+ years recent workers compensation claims handling experience required</li>
<li>At least 5 years of workers compensation claims experience preferred</li>
<li>Solid knowledge of workers compensation laws, policies, and procedures&rsquo;</li>
<li>Completion of IEA or equivalent courses</li>
<li>Proficiency in determining case value and negotiating settlements</li>
<li>Understanding of medical and legal terminology</li>
<li>Mathematical calculating skills</li>
</ul><ul><li>Well-developed verbal and written communication skills with strong attention to detail</li>
<li>Excellent organizational skills and ability to multi-task</li>
<li>Ability to type quickly, accurately and for prolonged periods</li>
<li>Proficient in Microsoft Office Suite
<ul><li>Ability to learn additional computer programs</li>
</ul></li><li>Reasoning ability, including problem-solving and analytical skills, i.e., proven ability to research and analyze facts, identify issues, and make appropriate recommendations and solutions for resolution</li>
<li>Ability to be trustworthy, dependable, and team-oriented for fellow employees and the organization</li>
<li>Seeks to include innovative strategies and methods to provide a high level of commitment to service and results</li>
<li>Ability to demonstrate care and concern for fellow team members and clients in a professional and friendly manner</li>
<li>Acts with integrity in difficult or challenging situations and is a trustworthy, dependable contributor.</li>
<li>COMPANYs&rsquo; operations involve handling confidential, proprietary, and highly sensitive information, such as health records, client financials, and other personal data. Therefore, maintaining honesty and integrity is essential for all roles within the company.</li>
<li>Must be able to reliably commute to meetings and events as required by this position</li>
</ul>
<br>
This description portrays in general terms the type and levels of work performed and is not intended to be all-inclusive or represent specific duties of any one incumbent. The knowledge, skills, and abilities may be acquired through a combination of formal schooling, self-education, prior experience, or on-the-job training.<br>
<br>
COMPANY is an Equal Opportunity/ Affirmative Action employer. We provide equal employment opportunities to all qualified employees and applicants for employment without regard to race, religion, sex, age, marital status, national origin, sexual orientation, citizenship status, veteran status, disability, or any other legally protected status. We prohibit discrimination in decisions concerning recruitment, hiring, compensation, benefits, training, termination, promotions, or any other condition of employment or career development.</div>

Workers Compensation Claims Examiner (California Jurisdiction)

Benecard Services Inc.

<p></p><div><div><div><div><div><div>The Claims Examiner &ndash; Vision Insurance is a key contributor within the Claims Department, responsible for accurately adjudicating vision and eye care claims in compliance with Medicaid, Medicare, and commercial payer guidelines. This role supports operational excellence by ensuring timely payments, regulatory compliance, and high-quality service to providers and internal stakeholders. The Claims Examiner plays an active role in meeting departmental performance metrics and supporting audits, reporting, and workflow oversight.</div><div></div><div><br>
This is a fully on-site role, and employees are expected to report to the Clifton, New Jersey office five days per week and is a Union position.</div><div></div><div><b><br>
Key Responsibilities</b></div><ul><li>
Review, evaluate, and adjudicate vision and eye care insurance claims in accordance with payer guidelines, including Medicaid, Medicare, and Coordination of Benefits (COB) rules</li><li>
Process complex or high-dollar claims requiring supervisory overrides</li><li>
Distribute daily claim workloads and support operational workflow efficiency</li><li>
Prepare and maintain documentation for internal and external audits</li><li>
Ensure compliance with prompt pay regulations and timely filing requirements</li><li>
Research and resolve rejected, denied, or pending claims, including billing corrections and resubmissions</li><li>
Analyze remittance advice (EOBs/ERAs) and communicate findings as needed</li><li>
Support monthly claims reporting and departmental performance tracking</li><li>
Collaborate with leadership to meet monthly productivity and accuracy goals</li><li>
Respond promptly and professionally to internal and external communications</li><li>
Perform additional duties as assigned to support claims operations and leadership initiatives</li></ul><div></div><div><b><br>
Required Qualifications:</b></div><ul><li>
5+ years of experience adjudicating and processing healthcare claims, preferably in vision insurance or eye care</li><li>
Strong knowledge of Medicaid and Medicare claim processing</li><li>
Proficiency with CPT, ICD-10, HCPCS codes, and modifiers, including billing and coding edits</li><li>
Solid understanding of Third-Party Liability (TPL) and Coordination of Benefits (COB) rules</li><li>
Experience with electronic claims submission, clearinghouses, and billing resubmission processes</li><li>
In-depth knowledge of HCFA-1500 (CMS-1500) and electronic billing standards</li><li>
Familiarity with appeals and reconsideration processes for government payers</li><li>
Experience researching and resolving claim denials and timely filing issues</li><li>
Working knowledge of AS400 or similar claims processing systems</li><li>
Intermediate to advanced Microsoft Office skills, with emphasis on Excel</li><li>
Strong attention to detail, analytical skills, and ability to manage deadlines in a high-volume environment</li></ul><div></div><div><b><br>
Preferred Qualifications:</b></div><ul><li>
Previous leadership experience would be preferred</li><li>
Certified Professional Coder (CPC/CBC) and/or Certified Professional Biller (CPB)</li><li>
Prior experience in vision plans, optometry, ophthalmology, or eye care billing</li><li>
Experience supporting or participating in claims audits or compliance reviews</li></ul><div></div><div><b><br>
Why Join Us?</b></div><ul><li>
Be part of a collaborative claim&rsquo;s leadership-focused environment</li><li>
Opportunity to specialize in eye care and vision insurance claims</li><li>
Role offers stability, growth, and exposure to complex adjudication and compliance work</li></ul><p></p><p><br>
National Vision Administrators</p><p>
For over 40 years, National Vision Administrators (NVA) has been meeting the vision benefit needs of public employer groups, Health &amp; Welfare Funds, Associations and Coalitions. Providing millions of people throughout the United States with vision care programs that help them be smarter buyers of eye care and eyewear, NVA is particularly well suited to address today's health benefit challenges as it relates to eye care. We offer cost-effective, customized vision benefit programs that are clinically integrated. We are proud of the fact that we have retained over 99% of our clients and believe it is the greatest testimony to the high-quality benefits and service satisfaction we provide to both our clients and their members. Headquartered in Clifton, New Jersey.</p><p>
Website: http://www.e-nva.com</p><p>
We are an equal opportunity employer</p></div></div></div></div><br>
Monday - Friday 8:30am - 5:00pm</div>

Claims Examiner

Utica National Insurance Group

<div><p><b>The Company</b>
</p><p>At Utica National Insurance Group, 1,400 employees countrywide take our corporate promise to heart every day: To make people feel secure, appreciated, and respected.</p>
<p>
Utica National Insurance Group is an &quot;A&quot; rated $2.0B award-winning, nationally recognized property &amp; casualty insurance carrier.</p>
<p>
Operating along the Eastern half of the United States, based in our Home Office in Central New York, with Regional Office locations including NYC, Dallas and Charlotte.</p>
<p><b>
What you will do</b></p>
<p>
The Property Large Loss Examiner will handle personal and commercial large loss claims and complex claims. With attention to customer service and skills in investigation and negotiation, the Examiner will meet the needs of our insureds and engage in timely claims resolution. As a more senior individual contributor role, this position will require broad technical knowledge at an advanced level. This role will be a hybrid position reporting to New Hartford, NY; Buffalo, NY; or Charlotte, NC.</p>
<p><b>
Key responsibilities</b></p>
<ul>
<li>Direct handling of both personal and commercial large loss claims with a high level of customer service.</li>
<li>Handles Property claims of a complex nature; performs claims investigations and handles matters requiring broad technical knowledge at an expert level.</li>
<li>Operates on an independent basis with little supervision; mitigates, negotiates and settles claims within assigned authority with a strong focus of overall claim resolution.</li>
<li>Assist in selection, and some oversight, of independent adjusters and coverage counsel.</li>
<li>Reviews court decisions, and coverage interpretations, and is required to have a broad knowledge and understanding of Property law and claim practices.</li>
<li>Responsible for reporting on large losses, litigation reports and reports to reinsurance as needed.</li>
<li>Assists in the development and training of claims personnel in Property department.</li>
<li>Performs other tasks as assigned.</li>
</ul>
<p><b>What you need:</b></p>
<ul>
<li>4 year college degree preferred or equivalent experience.</li>
<li>4-8 years of Property claims experience demonstrating expertise in underlying coverages, broad background in litigated matters and development.</li>
</ul>
<p><b>Licensing</b></p>
<p>
Required to obtain your license(s) as an adjuster in the state(s) in which you are assigned to adjust claims. Licensing must be obtained within the timeframe set forth by the Company and must be maintained as needed throughout your employment.</p><br>
<p></p>
<p>
Salary range: $81,000 - $120,000</p>
<p>
The final salary to be paid and position within the internal salary range is reflective of the employee&rsquo;s work experience, their geographic location, education, certification(s), scope and responsibilities in the role, and additional qualifications.</p><br>
<p></p>
<p><b>
Benefits
</b></p><p>We believe strongly that talented people are core to our success and are attracted to companies that provide competitive pay, comprehensive benefits packages, career advancement and challenging work opportunities. We offer a Comprehensive Benefits Plan for full time employees that include the following:</p>
<ul>
<li>Medical and Prescription Drug Benefit</li>
<li>Dental Benefit</li>
<li>Vision Benefit</li>
<li>Life Insurance and Disability Benefits</li>
<li>401(k) Profit Sharing and Investment Plan (Includes annual Company financial contribution and discretionary Profit Sharing contribution based upon annual company financial results)</li>
<li>Health Savings Account (HSA)</li>
<li>Flexible Spending Accounts</li>
<li>Tuition Assistance, Training, and Professional Designations</li>
<li>Company-Paid Family Leave</li>
<li>Adoption/Surrogacy Assistance Benefit</li>
<li>Voluntary Benefits - Group Accident Insurance, Hospital Indemnity, Critical Illness, Legal, ID Theft Protection, Pet Insurance</li>
<li>Student Loan Refinancing Services</li>
<li>Care.com Membership with Back-up Care, Senior Solutions</li>
<li>Business Travel Accident Insurance</li>
<li>Matching Gifts program</li>
<li>Paid Volunteer Day</li>
<li>Employee Referral Award Program</li>
<li>Wellness programs</li>
<li>Personal Insurance Discount</li>
</ul>
<p><b>Additional Information:</b></p>
<p>
This position is a full time salaried, exempt (non overtime eligible) position.</p>
<p>
Utica National is an Equal Opportunity Employer.</p>
<p>
Apply now and find out what it&rsquo;s like to be a part of an amazing team, thrive in an exciting environment and work for a company you can be proud of. Once you complete your application, you can monitor your status in the hiring process by logging into your profile. A representative from our Talent Acquisition team will be in touch regarding any change in your candidacy.
</p><p>#LI-HL1</p></div>

Property Large Loss Examiner (hybrid)

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