medical claims examiner

Administrative Concepts, Inc

<p>Are you looking for a career with an established company who values its employees? Administrative Concepts, Inc. (ACI) is a fast-growing company that offers its employees meaningful work and a positive environment. Founded in 1997, ACI is a nationally licensed, full-service, Third-Party Administrator providing enrollment, fulfillment and claims processing services for various insurance lines in the medical claims industry.</p><p><b>GENERAL PURPOSE OF THE JOB:</b> Review and process claims in accordance with training, guidelines, carrier directives, and policy provisions.</p><p><b>ESSENTIAL DUTIES AND RESPONSIBILITIES:</b></p><ul><li>Responsible for reviewing and maintaining a working knowledge of policy and state mandated insurance requirements.</li><li>Responsible to review and process claims for assigned accounts and back up as needed.</li><li>Prepare large claim files for review and send notifications in accordance with best practices for large claims.</li><li>Meet daily/weekly production goals established by management while maintaining processing and financial accuracy standards (95% minimum accuracy required).</li><li>Request refunds, voids, and no-pay adjustments as needed.</li><li>Respond to phone and email inquiries from clients, customers, and business partners (agents, brokers) when needed.</li><li>Provide customer service assistance in responding to benefit and claim questions.</li><li>Respond to questions and specific requests and provide complete information and documentation as needed.</li><li>Responsible to complete special projects.</li><li>Request subrogation and reimbursement letters from appropriate source.</li><li>Review and monitor the suspended claims list to ensure claims are processed within appropriate time limits.</li><li>Complete training rolled out by HR and claim management throughout the year.</li><li>Attend all individual, department and organizational meetings.</li><li>Uphold all company policies, procedures, and HIPAA guidelines</li><li>Adhere to the schedule they have selected, begin work on time.</li><li>Responsible to perform in accordance with all policies and provisions outlined in the ACI handbook.</li><li>Examiners must obtain and maintain individual adjuster licenses within the first twelve months of employment.</li><li>Other claim department duties as assigned by the manager.</li></ul><p><b>DESIRABLE QUALIFICATIONS:</b></p><ul><li>Knowledge of industry and medical terminology and codes</li><li>Understanding of the adjudication process</li><li>Ability to prioritize and organize</li><li>Strong verbal and written communication skills</li><li>Strong data entry skills</li><li>Experience with MS Office</li></ul><p>Pay: $21.00 - $24.00 per hour</p><p>Benefits:</p><ul><li>401(k)</li><li>Dental insurance</li><li>Health insurance</li><li>Paid time off</li><li>Vision insurance</li><li>Work from home</li></ul><p>Work Location: Remote</p>

Medical Claims Examiner (Remote)

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

<div>
 ATHENS POSITION DETAILS
 <br/>
 <br/>
 <strong>
  Position Title:
  <br/>
  <br/>
 </strong>
 Assistant Claims Examiner - Flex
 <br/>
 <br/>
 <strong>
  Department:
  <br/>
  <br/>
 </strong>
 Workers&rsquo; Compensation
 <br/>
 <br/>
 <strong>
  Reports To:
  <br/>
  <br/>
 </strong>
 Claims Supervisor
 <br/>
 <br/>
 <strong>
  FLSA Status:
  <br/>
  <br/>
 </strong>
 Non-Exempt
 <br/>
 <br/>
 <strong>
  Job Grade:
  <br/>
  <br/>
 </strong>
 6
 <br/>
 <br/>
 <strong>
  Career Ladder:
  <br/>
  <br/>
 </strong>
 Next step in progression could include Future Medical Examiner or Claims Examiner Trainee
 <br/>
 <br/>
 <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!
 <br/>
 <br/>
 <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.
 <br/>
 <br/>
 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.
 <br/>
 <br/>
 <strong>
  Primary Responsibilities
  <br/>
  <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:
 <br/>
 <br/>
 <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
   <br/>
   <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>
  <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
   <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
 <br/>
 <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.
 <br/>
 <br/>
 <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!
 <br/>
 <br/>
 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

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

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

St. Luke's Health System

<div><div>At St. Luke&rsquo;s, we pride ourselves on fostering a workplace culture that values diversity, promotes collaboration, and prioritizes employee well-being. Our commitment to excellence in patient care extends to creating an environment where our team can thrive both personally and professionally. With opportunities for growth, competitive benefits, and a supportive community of colleagues, St. Luke&rsquo;s is truly a great place to work.</div><div></div><div><b><br>
Remote work can be supported in Idaho only, per Idaho adjuster rules.</b></div><div></div><div><br>
The Sr. Claims Examiner is responsible for the investigation and administration of St. Luke&rsquo;s Health System Employee workers&rsquo; compensation claims.<br>
<br>
<b>What You&rsquo;ll Do:</b><br>
<ul><li>Lead complex claim management - Oversee a portfolio of workers&rsquo; compensation claims, including sophisticated occupational disease cases requiring in-depth analysis of pre-existing medical conditions, environmental exposures, and causation.</li><li>Drive compensability decisions - Conduct comprehensive investigations, leveraging policy interpretation, regulatory research, court rulings, and collaboration with employees, medical providers, employers, and legal counsel to make well-supported determinations.</li><li>Own financial stewardship - Establish and proactively manage claim reserves, ensuring accurate forecasting and responsible cost management.</li><li>Deliver exceptional case oversight - Maintain current, well-documented claim files through consistent communication and proactive follow-up with all stakeholders.</li><li>Ensure accurate benefit administration - Calculate and issue time-loss and impairment benefits, file required state documentation in compliance with Idaho Workers&rsquo; Compensation Law, and authorize appropriate medical payments.</li><li>Influence settlement strategy - Analyze exposure and provide thoughtful recommendations on lump sum settlements; negotiate settlements within delegated authority and in partnership with leadership.</li><li>Maximize recovery opportunities - Identify and pursue third-party recovery opportunities to mitigate claim costs when applicable.</li><li>Contribute to workplace safety insights - Partner with the Safety Officer to identify trends, serious injuries, and occupational disease patterns, helping drive preventative and corrective measures.</li></ul>
<br>
<b>Qualifications:</b><br>
<ul><li>Bachelor's Degree or experience in lieu of</li><li>4 years' relevant experience</li><li>Independent Adjuster's License</li></ul></div></div>

Senior Claims Examiner

Jewelers Mutual Group

<div><p><b>Summary:</b><br>
The Personal Lines (PL) Claims Examiner is responsible for handling claims inclusive of jewelry and other products from our personal lines customers located in the United States and Canada.</p><br>
<p><b>
Why Jewelers Mutual:</b><br>
Since 1913 we&rsquo;ve been committed to supporting the Jewelry industry and putting customers at the center of everything we do. With over a century of trusted expertise, we&rsquo;re financially strong, forward-thinking, and driven by curiosity. Guided by our core values of Agility, Accountability, and Relevancy, we lead through innovation.</p>
<p>
As a technology focused organization, we embrace cutting-edge tools and data-driven insights to continuously improve our products, services, and customer experience. Our mission is to be the industry&rsquo;s most trusted advisor by investing in our people, adopting new technologies, and striving for excellence.</p>
<p>
We&rsquo;re dedicated to fostering growth through collaboration, powered by bold thinking, teamwork, and the passion of our people.</p>
<p><b>
Here, you&rsquo;ll:</b></p>
<ul>
<li>Move fast and embrace change</li>
<li>Always look for better ways</li>
<li>Grow, thrive, and help shape what&rsquo;s next</li>
</ul>
<p>Join us and be part of a culture where you can make an impact while building your future.</p>
<p><b>
What You&rsquo;ll Do:</b></p>
<ul>
<li>Provides exceptional service to internal and external customers.</li>
<li>Investigates and reviews coverage in conjunction with legal precedence. Examine investigator&rsquo;s reports or similar claims precedents to determine extent of coverage and liability.</li>
<li>Evaluates exposure(s) based upon an office or field investigation. Directs the efforts of external claim professionals such as adjusters, SIU investigators, and attorneys during the investigation.</li>
<li>Collaborates with jewelers, underwriters, loss prevention and sales staff.</li>
<li>Aggressively fights fraud and works with our SIU in compliance with local and state regulations.</li>
<li>Establishes and maintains accurate reserves based upon company guidelines.</li>
<li>Pays claimant/insured amount due according to settlement agreement and company procedures.</li>
<li>Maintains excellent written and verbal correspondence with all parties involved on the claim.</li>
<li>Identifies and assists with recovery activities.</li>
<li>May be required to provide testimony under oath on claims in litigation.</li>
</ul>
<p>To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.</p>
<p><b>
What You&rsquo;ll Bring:</b></p><br>
<ul>
<li>High School Diploma or GED</li>
<li>Proficiency in Microsoft suite applications including Word, Excel, Outlook, and PowerPoint</li>
<li>Ability to obtain/maintain an adjuster&rsquo;s license</li>
<li>Bachelor&rsquo;s degree from four-year college or university, or an equivalent combination of education and experience</li>
<li>At least 2 years of claims adjusting experience</li>
<li>Property/casualty insurance background</li>
<li>Jewelry industry experience</li>
</ul>
<p><b>Physical Requirements</b></p>
<ul>
<li>Prolonged periods sitting at a desk and working on a computer.</li>
<li>Occasionally required to stand; walk; use hands to finger, handle, or touch objects or controls; and talk or hear.</li>
</ul>
<p><b>What We Offer You:</b></p>
<ul>
<li><b>Competitive Compensation &amp; Benefits:</b> Includes performance bonuses, generous paid time off, and a top-tier retirement program with 401(k) matching and additional company contributions.</li>
<li><b>Collaborative Culture</b>: Work alongside talented, passionate peers who value ownership and continuous learning.</li>
<li><b>Community &amp; Giving</b>: Benefit from 50% charitable gift matching and paid volunteer time to support nonprofit causes</li>
<li><b>Great Place to Work&reg; Certified</b>: Join a team recognized for an environment of innovation and growth.</li>
</ul>
<p><b>Accessibility and Accommodations</b><br>
We are committed to providing an inclusive and accessible recruitment process. If you require accommodation at any stage of the application or interview process, please let us know by contacting jmrecruiting@jminsure.com.</p></div>

PL Claims Examiner

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