insurance claims examiner

J.F. Terry Associates, Inc.

<p><b>IMMEDIATE NEED for Insurance Claims Professional. Salary to be determined based on experience.</b></p><p>The ideal candidate must have claims experience. Work from home options available.</p><p>Founded in 1969, J.F. Terry Associates is a multi-line insurance claims adjusting firm serving the Mid-Atlantic states including New England, Florida and California. We handle the claims of leading insurance companies, self-insureds, TPAs, transportation companies and legal defense firms.</p><p><b>Responsibilities include but are not limited to</b>:</p><ul><li>Maintain a strong sense of urgency in responding to the needs of our clients.</li><li>Obtain interviews and recorded statements from involved parties.</li><li>Prepare timely, clear and concise reports to clients in the client&rsquo;s preferred report format.</li><li>Communicate as needed with the client to ensure the assignment is being completed accurately and the client&rsquo;s needs are being met.</li><li>Analyze and evaluate special damages including auto estimates, property estimates, personal property inventories, medical bills, lost wage statements and medical reports.</li><li>Negotiate and conclude claims.</li><li>Analyze insurance coverage issues on specific claims and make recommendations to the client.</li><li>Provide customized services, when needed, to satisfy the individual requirements of our clients.</li><li>Comfortable in fast paced environment.</li><li>Participate in marketing activities as required.</li><li>Communicate well with leadership, all team members.</li><li>Friendly personality with ability to establish rapport with clients and vendors.</li><li>Positive, upbeat attitude with the ability to work as a team.</li></ul><p><b>QUALIFICATIONS:</b></p><ul><li>Claims Handling Experience REQUIRED</li><li>Able to work in a fast paced environment.</li><li>Liability Claims Experience</li><li>Property Damage Claims Experience</li><li>Casualty Claims Experience</li><li>A high degree of professionalism and strong work ethic coupled with a sense of responsibility and integrity.</li><li>Attention to detail and ability to effectively prioritize work.</li><li>Strong organizational skills.</li><li>Excellent interpersonal and communication skills (written and verbal). Can interact with all levels in an organization, internally and externally, with a calm and friendly attitude, especially when dealing with difficult situations.</li><li>Excellent judgment and discretion required in handling highly sensitive, privileged and confidential information in a respectful manner.</li><li>Ability to work under minimal supervision, tight time constraints, and periodic high volume circumstances.</li><li>Willingness and ability to take direction from various sources required.</li><li>Proficiency with Microsoft Office (Outlook, Excel, Word, Powerpoint) preferred.</li></ul><p><b>BENEFITS:</b></p><ul><li>401K match</li><li>Paid Time Off</li><li>Work From Home Schedule</li><li>Medical and Dental Benefits to be reviewed after first successful review.</li></ul><p>Pay: $45,000.00 - $60,000.00 per year</p><p>Benefits:</p><ul><li>401(k)</li><li>Dental insurance</li><li>Flexible schedule</li><li>Health insurance</li><li>Paid time off</li></ul><p>Education:</p><ul><li>Bachelor's (Required)</li></ul><p>Experience:</p><ul><li>Insurance: 5 years (Required)</li><li>Claims Handling: 5 years (Required)</li></ul><p>Ability to Commute:</p><ul><li>Newtown Square, PA 19073 (Required)</li></ul><p>Work Location: In person</p>

Insurance Claims Examiner

Prudential

<div><p>Job Classification:</p>
Operations - Insurance Operations<p></p><div>
The Disability Claim Examiner will be responsible for handling a claim block of disability claims and Absence claims. The Claim Examiner is accountable for ensuring optimal claims handling and timely, accurate decisions. In addition, the role requires but is not limited to the following skills:<br>
<br>
<ul><li>Will effectively and accurately manage a block of Disability and / Absence claims
</li><li>Focus on customer experience to deliver the best experience for our customers</li><li>Demonstrated ability to deliver accurate, dependable, and trustworthy service to our customers.</li><li>A strong customer focus evidenced through maintaining customer relationships.</li><li>Strong analytical reasoning
</li><li>Strong communication skills both written and verbal</li><li>Ability to work to independently in a fast-paced, metrics driven environment
</li></ul><br>
JOB REQUIREMENTS:<br>
<ul><li>2-3 years experience in Short Term Disability and /or Absence claim management prefered</li><li>Claim/risk management skills and technical knowledge in contract interpretation and administration</li><li>Success in achieving Individual Development goals.</li><li>Goal oriented with an ability to organize and analyze information</li><li>Strong critical thinking skills, communication, organization and time management skills</li><li>Proven customer service skills</li><li>Demonstrated ability to adapt to the changing needs of an organization</li><li>PC skills required (i.e., Windows based environment; Word; Excel; PowerPoint)</li><li>College degree preferred</li></ul><br>
<b>
This position requires candidates to be onsite in our Portland, ME office during the initial training and coaching period. Following this period, work arrangements may evolve based on business needs and individual readiness.</b></div><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 $53,300.00 to $88,000.00. 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>

Group Insurance Integrated Claims Examiner

State of Utah

<p></p><div><p><b>Disability Claims Examiner I</b></p><p><b>
FT / PT Status &ndash; </b>Full-Time<br>
<b>Salary &ndash; </b>$23.15 - $23.15 Hourly Wage
<br>
<b>Remote Work / In-Office &ndash; </b>In-Office / On-Site<br>
<br>
<b>Recruiter &ndash; </b>Makenna Powell | makennapowell@utah.gov | 801-526-4353<br>
<b>Application Deadline &ndash; </b>10/7/2026</p><p></p><p><b><br>
Key Responsibilities</b></p><p><br>
The Department of Workforce Services (DWS) is seeking four (4) motivated and highly skilled Disability Claims Examiner I's to join the Disability Determination Services (DDS) team in our Salt Lake City, UT office.<br>
<br>
Posting will be used to fill equivalent positions for 6 months.<br>
Remote work will be considered after a 1 year probationary period and if all performance standards are met.</p><p><b><br>
Watch our video!</b> Becoming A Disability Examiner</p><p><b>
Principal Duties</b><br>
The Claims Examiner I performs the following tasks:</p><ul><li>
Adjudicates a variety of medical disability claims for the Social Security Administration in compliance with federal laws.</li><li>
Analyzes, summarizes and/or reviews data; reports findings, interprets results and/or makes recommendations.</li><li>
Assesses client/patient needs and develops and implements plans to meet those needs.</li><li>
Schedules and/or coordinates appointments, meetings, facilities or other activities; gathers materials and follows up as needed.</li><li>
Writes or drafts correspondence, reports, documents and/or other written materials.</li><li>
Makes authorized adjustments and corrections to previously processed claims.</li><li>
Identifies and develops sources of evidence from claim folder application, the applicant, government sources, medical sources, district offices, private institutions or employers, deciding the most effective way to procure such information.</li><li>
Reviews cases, applications, files and records to determine action to be taken.</li><li>
Decides the need for additional data or information.</li><li>
Authorizes the means necessary to obtain the required information.</li></ul><p></p><p><b>
</b><b>Qualifications</b></p><p><br>
The model applicant for this position is someone who:</p><ul><li>
Has a Bachelor's Degree.</li><li>
Has at least one year of experience providing excellent customer service.</li><li>
Has current or prior experience working as a Disability Examiner for DDS.</li></ul><p><b>
Preference</b><br>
Preference points will be given for the following:</p><ul><li>
Current or previous work experience with Disability Determination Services (DDS).</li></ul><p></p><p><b>
About the Role</b></p><p><b>
Location</b> &ndash;
<br>
210 W. Harris Ave<br>
Salt Lake City, UT, 84115<br>
United States
<br>
<b>Background Check Required</b> &ndash; You must successfully pass a criminal history check.<br>
<b>Drug Test Required</b> &ndash; No
<br>
<b>Schedule Code</b> &ndash; B - Competitive Career Service</p><p><b>
Why You Should Join Our Team</b><br>
In Utah, we believe hard work is important, but balance is essential. Finding work/life balance is a vital element to our culture. To find out more about WHY Utah, click here. Other benefits may include:</p><ul><li><b>
Job Stability: </b>Enjoy the security and reliability of employment within a well-established organization.</li><li><b>
Career Growth:</b><b> </b>Develop valuable skills and gain opportunities for leadership within a large organization.</li><li><b>
Meaningful Work: </b>Contribute to an important service that benefits the community and supports organizational goals.</li><li><b>
Supportive Work Environment:</b><b> </b>Be part of a team that values cooperation, strong work ethics, and mutual support.</li></ul><p><b>
The Agency</b><br>
The mission of Workforce Services is we strengthen Utah&rsquo;s communities by connecting the workforce to new opportunities and providing services to individuals and families in need. Today, more than 2,200 Workforce Services employees assist individuals in preparing for and finding jobs, meeting workforce needs of Utah businesses, administering temporary assistance, and providing economic data and analysis. Through a collaborative approach, the department has served millions of Utahns and has become a leader on several statewide initiatives. These include intergenerational poverty, homelessness, affordable housing, supporting refugees, helping rural communities, serving veterans and individuals with disabilities, and getting Utahns trained and back to work. To learn more about Workforce Services, click here.</p><p><b>
EEO Statement</b><br>
The State of Utah is committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender identity, or Veteran status. We also consider qualified applicants regardless of criminal histories, consistent with legal requirements. For accommodations, please contact (801) 957-9390.</p></div><div></div>

Disability Claims Examiner I

Athens Administrators

<div><div><b>ATHENS POSITION DETAILS</b></div>
<div></div><div><div><div><div><div><b>Position Title:</b></div>
</div><div><div>Assistant Claims Examiner</div><br>
</div></div><br>
<div><div><div><b>Department:</b></div>
</div><div><div>Workers&rsquo; Compensation</div><br>
</div></div><br>
<div><div><div><b>Reports To:</b></div>
</div><div><div>Claims Supervisor</div><br>
</div></div><br>
<div><div><div><b>FLSA Status:</b></div>
</div><div><div>Non-Exempt</div><br>
</div></div><br>
<div><div><div><b>Job Grade:</b></div>
</div><div><div>6</div><br>
</div></div><br>
<div><div><div><b>Career Ladder:
</b></div></div><div><div>Next step in progression could include Future Medical Examiner or Claims Examiner Trainee</div>
</div></div><br>
</div></div><div></div><div><b>ATHENS ADMINISTRATORS</b></div>
<div>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!</div>
<div></div><div><b>POSITION SUMMARY</b></div>
<div>Athens Administrators has an immediate need for an experienced Assistant Claims Examiner 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. The Assistant Claims Examiner 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.</div>
<div></div><div><b>PRIMARY RESPONSIBILITIES</b></div>
<div>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:</div>
<div></div><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>
<li>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>
<li>Provide updates of claims status to Senior Claims Examiners and Athens management</li>
<li>Prepare professional, well written correspondence and other communications</li>
</ul>
<div></div><div><b>ESSENTIAL POSITION REQUIREMENTS
</b></div><div>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.</div>
<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>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>
<li>Knowledge of workers compensation laws, policies, and procedures</li>
<li>Understanding of medical and legal terminology</li>
<li>Must demonstrate accuracy and thoroughness in work product</li>
<li>Ability to sit for prolonged periods of time</li>
<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</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>
<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>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</li>
</ul><div><b>APPLY WITH US</b></div>
<div>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</div>
<div></div><div>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.</div>
<div></div><div>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.</div>
<div></div><div><b>THANK YOU!</b></div>
<div>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!</div>
<div></div><div>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 <b>https://www.athensadmin.com/careers/why-work-here</b></div></div>

Assistant Claims Examiner

Kinsale Insurance Company

<div><p>As a Claims Examiner, you will play a key role in managing casualty claims from investigation through resolution. This position combines analytical thinking, decision-making, and negotiation to ensure fair and timely claim outcomes. You&rsquo;ll work closely with experienced claims professionals and legal partners while handling a diverse portfolio, including litigated claims. This is a great opportunity to grow your expertise in a fast-paced, team-oriented environment that values learning and career development.</p>
<h4 class="jobSectionHeader"><b>
What You&rsquo;ll Do</b></h4>
<ul><li>Manage a variety of casualty claims under the guidance of a Claims Supervisor</li>
<li>Conduct and coordinate investigations across all phases of the claims process</li>
<li>Evaluate liability and exposure to develop effective resolution strategies</li>
<li>Analyze policy coverage, make determinations, and draft clear coverage correspondence</li>
<li>Communicate claim decisions and updates with policyholders and key stakeholders</li>
<li>Maintain accurate, detailed, and timely documentation within claim files</li>
<li>Oversee litigated claims by appointing and managing defense counsel</li>
<li>Drive claims and litigation toward efficient and fair resolution</li>
<li>Participate in mediations, settlement discussions, and trials as needed</li>
</ul><h4 class="jobSectionHeader"><b>What You Bring</b></h4>
<ul><li>Bachelor&rsquo;s degree in Business, Risk Management, or a related field</li>
<li>2+ years of experience handling commercial general liability claims involving bodily injury and property damage</li>
<li>Strong analytical, problem-solving, and decision-making skills</li>
<li>Excellent written and verbal communication abilities</li>
<li>Experience managing litigated claims and working with defense counsel</li>
<li>Ability to analyze medical records, contracts (including risk transfer provisions), property damage estimates, and litigation documents</li>
<li>Strong organizational and time management skills with the ability to multitask</li>
<li>Proficiency in Microsoft Office (Word, Excel, Outlook, PowerPoint)</li>
<li>A collaborative mindset with strong negotiation skills</li>
</ul>
<p><i>Adjuster licenses or industry designations are a plus.</i></p>
<h4 class="jobSectionHeader"><b>
Why You&rsquo;ll Love Working at Kinsale</b></h4>
<ul><li><b>Competitive Pay &amp; Bonus Opportunities</b> &ndash; Rewarding performance and initiative.</li>
<li><b>Comprehensive Benefits</b> &ndash; Health, dental, and vision insurance with up to $3,600 (individual) or $6,800 (family) in HSA contributions per year.</li>
<li><b>Work-Life Balance</b> &ndash; Generous paid time off including 22 days of PTO and 10 paid company holidays.</li>
<li><b>Career Growth</b> &ndash; Clear promotion paths, mentorship, and ongoing professional development.</li>
<li><b>Retirement &amp; Security</b> &ndash; Up to 6% matching 401(k) contributions on base salary and bonus, standard life insurance, and disability coverage.</li>
<li><b>Continuous Learning</b> &ndash; Annual $3,000 reimbursement for educational training and certifications.</li>
</ul><h4 class="jobSectionHeader"><b>Integrity &amp; Responsibility</b></h4>
<p>
Kinsale values strong financial responsibility. A credit check may be conducted as part of the selection process for roles that require sound judgment and trustworthiness.</p>
<h4 class="jobSectionHeader"><b>
Ready to Apply?</b></h4>
<p>
If you&rsquo;re a detail-oriented claims professional who thrives in a collaborative and fast-paced environment, this is your opportunity to grow your career with Kinsale Insurance. Join a company that values innovation, excellence, and continuous learning.</p>
<p><b>
Apply today and take the next step in your career!</b></p></div>

Claims Examiner

DOCTORS HEALTHCARE PLANS, INC.

<div><p>The<b> Claims Examiner III </b>is a senior-level claims professional responsible for the accurate and timely adjudication of complex professional and institutional claims in accordance with regulatory requirements, contractual agreements, and internal policies. This role supports departmental workflow oversight, assists leadership with productivity and quality monitoring, and serves as a subject matter resource to team members to ensure operational excellence and compliance with CMS and organizational standards.<br>
<br>
<b>Key Responsibilities:</b></p><div><ul><li>
Review, analyze, and adjudicate professional and institutional claims, including high-dollar and complex cases.</li><li>
Process Member Reimbursement claims in accordance with plan benefits and regulatory guidelines.</li><li>
Ensure claims are processed accurately, timely, and in compliance with CMS regulations, state guidelines, and internal policies.</li><li>
Assist the Claims Manager and/or Assistant Director in monitoring daily, weekly, and monthly workflow to meet production and quality targets.</li><li>
Generate and analyze reports to track productivity, aging inventory, and pending items.</li><li>
Provide guidance and clarification to team members regarding claims processing rules, contract interpretation, and system functionality.</li><li>
Support the implementation and enforcement of departmental policies and procedures.</li><li>
Collaborate with leadership to ensure production, accuracy, and turnaround time metrics are consistently met.</li><li>
Communicate departmental goals, workflow strategies, and performance improvement initiatives to staff.</li><li>
Promote a positive work environment that supports staff engagement, accountability, and teamwork.</li><li>
Maximize system capabilities by ensuring proper utilization of claims processing tools and platforms.</li><li>
Identify process improvement opportunities and escalate system or configuration issues as needed.</li><li>
Perform additional duties as assigned.</li></ul><div><b>
Qualifications:</b></div></div><ul><li>
High School Diploma or GED</li><li>
Minimum of 3+ years of experience as a Medical Claims Examiner.</li><li>
Experience processing Medicare Advantage and/or managed care claims preferred.</li><li>
Strong experience with contract interpretation and benefit application.</li><li>
Working knowledge of CMS guidelines, Medicare regulations, and healthcare claims processing standards.</li><li>
Strong analytical and problem-solving skills.</li><li>
Proficiency in Windows-based systems and claims processing applications.<br>
</li></ul><div><i>
Note: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.</i></div><p><i>
No Third Party Agencies or Submissions Will Be Accepted.</i><br>
<br>
<i>Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP</i><br>
<br>
<i>Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.</i></p><p>
</p><p>3hOLMnYaLt</p></div>

Claims Examiner III

Crawford & Company

<div><div><div><b>We&rsquo;re Hiring: Senior Claims Examiner &ndash; Workers Compensation (California)</b><br>
<br>
 This is an exciting opportunity to join a global leader in claims management and make a meaningful impact through your expertise<br>
<br>
<b>Why You&rsquo;ll Love It Here:</b><br>
 Offers Work From Home Position<br>
 Compensation: $25.15 &ndash; $45.99 (hourly)<br>
 Excellent Crawford Benefits Supporting Financial, Physical &amp; Mental Wellness<br>
 Great Bonus Opportunity<br>
 Generous Employee Referral Bonus Program<br>
️ Access to Multiple Employee Discounts<br>
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We&rsquo;re looking for a <b>Senior Claims Examiner &ndash; Workers Compensation (California)</b> with a passion for claims management to join our team!<br>
 SIP certification is required<br>
 Proven experience handling California Workers Compensation claims<br>
 Strong background in managing advanced, large-loss, and complex cases<br>
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<b>Role Overview:</b><br>
 Investigate and settle advanced, large-loss, and complex claims promptly and equitably with minimal supervision.<br>
 Work within established authority on moderate-to-difficult claims, reviewing coverages, determining liability/compensability, collecting statements and essential information, and settling claims using best practices.<br>
<ul><li>️ Evaluate and set reserves using independent judgment, support litigation preparation with supervisors and defense attorneys, and contribute to team development through training and mentorship.</li></ul></div></div><ul>
<li>Interprets and makes decisions using independent judgment on more complex and unusual policy coverages and determines if coverages apply to claims submitted.</li>
<li>Manages all aspects of investigative activity on complex claims. Directs the discovery and litigation strategy with legal counsel.</li>
<li>Analyzes claims activity and prepares reports for clients/carriers and management.</li>
<li>Establish reserves, using independent judgment and expertise and authorizes payments within scope of authority, settling claims in the most cost effective manner and ensuring timely issuance of disbursements.</li>
<li>Settles claims promptly and equitably and issues company drafts in payments for claims within authority limits.</li>
<li>Develops subrogation and third party recovery potential and follows reclaim procedures.</li>
<li>Analyzes claims activities and prepares reports for clients, carriers and/or management. Participates in claim reviews.</li>
</ul><ul><li>Bachelor's degree or equivalent experience required.</li><li>
Technical claims investigations/settling experience with 4-8 years experience in Claims or similar organization.</li><li>
Ability to work independently while assimilating various technical subjects..</li><li>
Strong written and oral communication, negotiation and presentation skills.</li><li>
Advanced analytical and problem solving skills, with the ability to manage and prioritize multiple projects.</li><li>
Effective advanced interpersonal skills to effectively interact with all levels of internal and external clients.</li><li>
Industry Designations: Preferred: IIA, AIC, AEI, and/or CPCU.</li><li>
License Requirements:Per State or Jurisdictional requirements.</li><li>
Workers Compensation (WC) Adjuster License required according to jurisdictional requirements</li></ul><p>
#LI-EM3 #LI-HYBRID</p>
Why Crawford?
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Because a claim is more than a number &mdash; it&rsquo;s a person, a child, a friend. It&rsquo;s anyone who looks to Crawford on their worst days. And by helping to restore their lives, we are helping to restore our community &ndash; one claim at a time.
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At Crawford, employees are empowered to grow, emboldened to act and inspired to innovate. Our industry-leading team pioneers new solutions for the industries and customers we serve. We&rsquo;re looking for the next generation of leaders to take this journey with us.
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We hail from more than 70 countries and speak dozens of languages, reflecting the global fabric of the audience we serve. Though our reach is vast, we proudly operate as One Crawford: united in purpose, vision and values. Learn more at www.crawco.com.
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When you accept a job with Crawford, you become a part of the One Crawford family.
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Our total compensation plans provide each of our employees with far more than just a great salary
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<ul><li>Pay and incentive plans that recognize performance excellence</li>
<li>Benefit programs that empower financial, physical, and mental wellness</li>
<li>Training programs that promote continuous learning and career progression while enhancing job performance</li>
<li>Sustainability programs that give back to the communities in which we live and work</li>
<li>A culture of respect, collaboration, entrepreneurial spirit and inclusion</li>
</ul><i>Crawford &amp; Company participates in E-Verify and is an Equal Opportunity Employer. M/F/D/V Crawford &amp; Company is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at Crawford via-email, the Internet or in any form and/or method without a valid written Statement of Work in place for this position from Crawford HR/Recruitment will be deemed the sole property of Crawford. No fee will be paid in the event the candidate is hired by Crawford as a result of the referral or through other means.</i></div>

Sr Claim Examiner-WC (CA)

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