senior premium auditor

Elevance Health

<div><p><b>Provider Auditor Senior</b> <b>-</b> <b>Audit</b></p><p></p><p><b>
Location: Atlanta, GA; Norfolk, VA &amp; Indianapolis, IN</b></p><p><b>
Hybrid 1:</b> This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office.</p><p></p><p><i>
Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.</i></p><p></p><p>
The <b>Provider Auditor Senior</b> conducts on-site reviews of medical charts, medical notes, itemized bills and providers contracts to ensure that a claim is paid in accordance with the contract, provider reimbursement policies, and industry standards.</p><p></p><p><b>
How you will make an impact:</b></p><ul><li>
Selects providers to be reviewed based on historical results of other reviews with providers, network management input and dollar volume of provider.</li><li>
Schedules review with provider, analyzes data to select claims to be reviewed, conducts review using medical charts, medical notes, itemized bills and provider contracts.</li><li>
Conducts exit interview with provider management team by presenting preliminary review results.</li><li>
Verifies dollar amount on claim is correct in claims system and writes report of the findings of the review and requests payments for any overpayments.</li><li>
Identifies aberrant patterns of billing and detects potential abuse.</li><li>
Mentors and trains Provider Auditor as needed.</li><li>
Drafts department policies and procedures and other educational materials.</li><li>
Works on task forces and committees representing functional area.</li></ul><p></p><p><b>
Minimum Qualifications:</b></p><ul><li>
Requires a BA/BS degree and a minimum of 3 years equivalent work experience; or any combination of education and experience, which would provide an equivalent background.</li></ul><p></p><p><b>
Preferred Skills, Capabilities and Experiences:</b></p><ul><li>
Certification as a Professional Coder preferred.</li></ul><br>
<p></p>
<p>Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.</p>
<p>Who We Are</p>
<p>Elevance Health is a health company dedicated to improving lives and communities &ndash; and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.</p>
<p>How We Work</p>
<p>At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.</p>
<p>We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.</p>
<p>Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.</p>
<p>The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.</p>
<p>Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.</p>
<p>Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.</p><p>
Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.</p></div>

Provider Auditor Senior

DAVIES

<div><h3 class="jobSectionHeader"><b>Description</b></h3><div><b><br>
Our Story</b></div><div>
Imagine being part of a team that&rsquo;s not just shaping the future but actively driving it. At <b>Davies North America</b>, we&rsquo;re at the forefront of innovation and excellence, blending cutting-edge technology with top-tier professional services. As a vital part of the global Davies Group, we help businesses navigate risk, optimize operations, and spearhead transformation in the insurance and regulated sectors.</div><div>
<br>
<b>What's in Store</b><br>
We are on the lookout for an experienced <b>Premium Audit Coordinator</b> who will work directly with the branch team to provide assistant functions to our field representatives. Reporting to the Branch Manager, you will perform a variety of tasks related to the preparation of reports and appointments. You will also spend time completing inbound calls with insureds and audit representatives to encourage the appropriate preparation for upcoming premium audits.</div><h3 class="jobSectionHeader"><b><br>
Key Responsibilities</b></h3><br>
<ul>
<li>
Acts as a liaison between the Phone Audit Manager and Phone Auditors to facilitate the flow of work</li>
<li>High call volume averaging 8-12 calls per hour during business hours</li>
<li>Acts as a liaison between insureds and field representatives when setting up audit or inspection appointments</li>
<li>Assists with determining needs, scheduling or cancelling appointments, or referring the insured to the correct staff person</li>
<li>Correspond with policyholders, CPA&rsquo;s, bookkeepers, agents to gather additional information as needed</li>
<li>Communicates audit needs to the insured to help ensure information is prepared for the Phone Auditor</li>
<li>Maintains and updates contact notes on each assigned job in AuSum</li>
<li>Makes calls to check on status of information including insurance agent calls</li>
<li>Handles all calls in a professional and welcoming manner and uses tact when explaining this process and reasoning for the inquiry</li>
<li>Attaches information and adds progress notes as it becomes available in AuSum</li>
<li>Assigns audits to Phone Auditors once information is received</li>
<li>Other duties as assigned</li>
</ul><div><br>
<b>This is a part-time (29 hours per week), remote role.</b></div><div></div><h3 class="jobSectionHeader"><b><br>
Skills, knowledge &amp; expertise</b></h3><br>
<ul>
<li>
Professional phone, chat, and email communication</li>
<li>High School Diploma or GED</li>
<li>Excellent computer skills including experience in the Microsoft Office Suite</li>
<li>Commitment to providing exceptional customer service</li>
<li>Communication: Balancing listening and talking, speaking, and writing clearly and accurately, influencing others, keeping others informed</li>
<li>Attention to Detail: Listen to information from policyholders and clients alike</li>
<li>Efficiency: Planning, managing time well, being on time, being cost conscious, thinking of better ways to do things</li>
<li>Multitasking: Handles distractions well, adaptable to new responsibilities; ability to quickly switch between tasks and adapt to changes easily</li>
<li>Proactive, independent, and takes initiative with consistent follow through</li>
<li>Superb communication skills, verbal and written, conducted in a timely manner</li>
<li>Superior time management skills with capability of working with and meeting deadlines</li>
<li>Exceptional capability to multi-task and prioritize with excellent organization and documentation skills in a fast-paced, dynamic work environment</li>
<li>Capable of working collaboratively and independently with minimal supervision</li>
<li>Exhibit discretion with sensitive and confidential information</li>
<li>Display a comfort level working with key people at all levels within an organization</li></ul><br>
<h3 class="jobSectionHeader"><b>
Benefits</b></h3><div><b><br>
Benefits</b></div><div>
At Davies North America, we are dedicated to supporting the well-being and future of our qualifying employees. Our comprehensive benefits package includes:</div><ul>
<li>Medical, dental, and vision plans to ensure your health and that of your family.</li>
<li>A 401k plan with employer matching to help you build a secure financial future.</li>
<li>Our time-off policies, including Discretionary Time Off (DTO) for exempt employees and Paid Time Off (PTO) package for non-exempt employees, reflect our commitment to promoting a healthy work environment.</li>
<li>Paid holidays.</li>
<li>Life insurance and both short-term and long-term disability plans, providing essential financial protection for you and your loved ones.</li>
</ul><div><b>Massachusetts Notice</b><br>
It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.<br>
</div><div><b>Diversity and Inclusion</b></div><div>
Davies is dedicated to fostering a diverse and inclusive workplace that embraces a wide range of perspectives and experiences. We believe that diversity of thought is essential for innovation and creativity, and we actively promote an environment where all voices are valued and heard.<br>
<br>
<b>Compensation Transparency:</b>
<br>
The salary range listed reflects the full compensation band for this role across all locations. Actual compensation will be based on factors such as skills, experience, qualifications, and geographic location, which may impact the final offer. We share ranges to remain transparent and consistent with pay equity practices.
<br>
<br>
<i>We do not use sites like Facebook, Craigslist, or Telegram to recruit or interview potential employees or contractors. If you have been asked to provide any information through any method other than our career portal, please email us at </i><i>recruitment@davies-group.com</i></div><br>
<h3 class="jobSectionHeader"><b>
About Davies</b></h3><div>
We are a specialist professional services and technology firm, working in partnership with leading insurance, highly regulated and global businesses.<br>
<br>
We help our clients to manage risk, operate their core business processes, transform and grow. We deliver professional services and technology solutions across the risk and insurance value chain, including excellence in claims, underwriting, distribution, regulation &amp; risk, customer experience, human capital, digital transformation &amp; change management.<br>
<br>
Our global team of more than 8,000 professionals operate across ten countries, including the UK &amp; the U.S. Over the past ten years Davies has grown its annual revenues more than 20-fold, investing heavily in research &amp; development, innovation &amp; automation, colleague development, and client service. Today the group serves more than 1,500 insurance, financial services, public sector, and other highly regulated clients.</div></div>

Premium Audit Coordinator (Part-Time, Remote)

<div><h2 class="jobSectionHeader"><b>Description</b></h2>
<div>
<p>As a Medical Claim Lead Auditor, you will apply your audit, project management and client management skills to lead client audits. You will serve as the team leader and primary interface with administrators. You will review discrepancy issues identified by field auditors, re-adjudicate claims, resolve open issues, and draft the final report. You will contribute to the creation of new tools and approaches.</p>
<p><b>
The Responsibilities</b></p>
<ul>
<li>Conduct pre-implementation and coverage specific audits and accurately document and record all audit findings</li>
<li>Understand client&rsquo;s plans and apprise team of unique provisions/issues prior to audit</li>
<li>Adjust workloads as necessary to achieve successful completion of project</li>
<li>Clearly communicate and professionally interact with vendor and audit team</li>
<li>Review documentation of potential discrepancies for thoroughness and accuracy</li>
<li>Resolve post-audit activities in an accurate and timely fashion</li>
<li>Write quality value-added draft report in a timely manner</li>
<li>Participate in client presentation of findings, when requested</li>
<li>Understand vendors&rsquo; processes, operating environment, and specific challenges and take them into account with daily work</li>
<li>Develop working relationship with vendor counterparts</li>
<li>Distribute individual claim/work queues to team in a timely manner</li>
<li>Efficiently utilize audit-specific analytic techniques, tools and processes</li>
<li>Ensure that Professional Excellence protocols are followed</li>
<li>Meet billable hours target</li>
<li>Seek opportunities to improve work processes and methods in pursuit of quality output and service delivery</li>
<li>Role will be working remotely within the posted locations.</li>
</ul>
<p><b>Qualifications</b></p>
<ul>
<li>5+ years&rsquo; experience in health claims adjudication gained preferably in a consulting environment and/or in a major insurance claims administrator or health plan environment</li>
<li>Solid understanding of health and welfare plan design and all areas of claims administration, as well as of vendors&rsquo; processes and operating environment</li>
<li>Familiarity with all plan types including consumer-driven, PPO, Indemnity and Managed Care</li>
<li>Must demonstrate a high level of claims administration knowledge, including experience with medical, dental, mental health and Medicare</li>
<li>Detailed knowledge of ICD-10 and CPT codes and coding protocols</li>
<li>Must have prior experience in medical claim auditing (e.g., re-evaluating medical claims that were previously processed for adherence to plan design and other program parameters).</li>
<li>Experience auditing both professional and facility claims types.</li>
<li>Must have experience auditing both benefits and pricing.</li>
<li>Excellent oral and written communications skills</li>
<li>Team player with strong work ethic</li>
<li>Self-directed; requiring very little supervision</li>
<li>Previous internal audit experience at a carrier or third-party external audit experience a plus</li>
<li>Bachelor's Degree preferred; High School Diploma required</li></ul><br>
<p></p>
</div>
<h2 class="jobSectionHeader"><b>Qualifications</b></h2>
<div>
<p><b>Compensation and Benefits</b></p>
<p>
Base salary range and benefits information for this position are being included in accordance with requirements of various state/local pay transparency legislation. Please note that base salaries may vary for different individuals in the same role based on several factors, including but not limited to location of the role, individual competencies, education/professional certifications, qualifications/experience, performance in the role and potential for revenue generation.</p>
<p><b>
Compensation</b></p>
<p>
The base salary compensation range being offered for this role is $90,000 to $98,000 USD per year.</p>
<p>
This role is also eligible for an annual short-term incentive bonus.</p>
<p><b>
Company Benefits</b></p>
<p>
WTW provides a competitive benefit package which includes the following (eligibility requirements apply):</p>
<ul>
<li><b>Health and Welfare: </b>Mental health/emotional wellbeing (including Employee Assistance Program), medical (including prescription drug coverage and fertility benefits), dental, vision, Health Savings Account, Commuter Accounts, Health Care and Dependent Care Flexible Spending Accounts, company-paid life insurance, supplemental life insurance, AD&amp;D, group accident, group critical illness, group legal, identity theft protection, wellbeing program, adoption assistance, surrogacy assistance, auto/home insurance, pet insurance, and other work/life resources.</li>
<li><b>Leave Benefits:</b> Paid Holidays, Annual Paid Time Off (includes paid state/local paid leave where required), Short-Term Disability, Long-Term Disability, Other Leaves (e.g., Bereavement, FMLA, ADA, Jury Duty, Military Leave, and Parental and Adoption Leave), <b>Paid Time Off</b></li>
<li><b>Retirement Benefits:</b> Contributory Pension Plan and Savings Plan (401k). All Level 38 and more senior roles may also be eligible for non-qualified Deferred Compensation and Deferred Savings Plans.</li>
</ul>
<p>Pursuant to the San Francisco Fair Chance Ordinance and Los Angeles County Fair Chance Ordinance for Employers, we will consider for employment qualified applicants with arrest and conviction records.</p>
<p>
Note that visa employment-based non-immigrant visa sponsorship and/or assistance is not offered for this specific job opportunity.</p>
<p>
This position will remain posted for a minimum of three business days from the date posted or until sufficient/appropriate candidate slate has been identified.</p>
<p><b>
EOE, including disability/vets</b></p></div></div>

Medical Claim Lead Auditor (Remote)

Deloitte

<div>
 <strong>
  Audit &amp; Assurance | Senior
  <br/>
  <br/>
 </strong>
 <strong>
  About Deloitte
 </strong>
 : When you work for us, you commit to a career at one of the largest and most prestigious professional services firms in the world. We have received numerous awards over the last few years, including Best Employer in the Middle East, and Best Consulting Firm, and the Middle East Training &amp; Development Excellence Award.
 <br/>
 <br/>
 <strong>
  Our Purpose
  <br/>
  <br/>
 </strong>
 Deloitte makes an impact that matters. Every day we challenge ourselves to do what matters most&mdash;for clients, for our people, and for society. We serve clients distinctively, bringing innovative insights, solving complex challenges and unlocking sustainable growth. We inspire our talented professionals to deliver outstanding value to clients, providing an exceptional career experience and an inclusive and collaborative culture. We contribute to society, building confidence and trust in the markets, upholding the integrity of organizations and supporting our communities.
 <br/>
 <br/>
 Our shared values guide the way we behave to make a positive, enduring impact:
 <br/>
 <br/>
 <ul>
  <li>
   Lead the way
  </li>
  <li>
   Serve with Integrity
  </li>
  <li>
   Take care of each other
  </li>
  <li>
   Foster inclusion
  </li>
  <li>
   Collaborate for measurable impact.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Audit &amp; Assurance | Senior:
  <br/>
  <br/>
 </strong>
 During Your Tenure As a Senior In Audit &amp; Assurance, You Will Demonstrate And Develop Your Capabilities In The Following Areas
 <br/>
 <br/>
 <ul>
  <li>
   Builds trust and credibility with stakeholders by seeking to understand their service levels expectations and what matters to them individually.
  </li>
  <li>
   Delivers high quality services by demonstrating a practical awareness of the impact of regulation and risk management on business processes and controls
  </li>
  <li>
   Takes responsibility for understanding key statistic and industry matters about entity before engagement begins.
  </li>
  <li>
   Adapts template referral instructions to clearly outline the scope of procedures to be performed, including the areas of audit focus. Understands the structure of the group audit and for whom the referral instructions are intended.
  </li>
  <li>
   Liaises effectively with onshore and offshore Centers of Excellence in the delivery of relevant tasks, understanding the scope of work delegated to them and the importance of providing accurate and complete information to them.
  </li>
  <li>
   Assists in tracking deliverables from component auditors and seeks to understand the relevance and importance of these
  </li>
  <li>
   Appropriately links risks, controls procedures and findings from allocated sections across the EMS file on a timely basis.
  </li>
  <li>
   Can articulate the audit quality milestones, the ways in which teams demonstrate completeness of milestones, and how the audit quality milestones contribute to audit quality.
  </li>
  <li>
   Understands the rationale behind the timings of the audit plan and is prepared to offer challenge around whether work can be performed earlier in the audit cycle.
  </li>
  <li>
   Prepares documentation by anticipating questions that reviewers may ask and distinguishes accounting judgements and conclusions from auditing judgements and conclusions.
  </li>
  <li>
   Understands that it is important to develop relationships beyond the finance function in order to better understand the entity's business and apply professional skepticism.
  </li>
  <li>
   Has a practical awareness of the risks around the engagement lifecycle and regulatory environment, and relevant practical protection policies.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Leadership Capabilities
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Builds own understanding of our purpose and values explores opportunities for impact.
  </li>
  <li>
   Demonstrates strong commitment to personal learning and development; acts as a brand ambassador to help attract top talent.
  </li>
  <li>
   Understands expectations and demonstrates personal accountability for keeping performance on track.
  </li>
  <li>
   Actively focuses on developing effective communication and relationship-building skills.
  </li>
  <li>
   Understands how their daily work contributes to the priorities of the team and the business.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Qualifications
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Degree in Accounting or related field. Graduate degree is desired.
  </li>
  <li>
   3+ years of experience in public auditing and accounting, preferably with Big Audit Firms.
  </li>
  <li>
   Supervise staff, inspect client financial records, compile and analyze data, prepare detailed audit reports and resolve accounting research issues.
  </li>
  <li>
   Demonstrate ability to plan and manage engagements and people along with ensuring deliverables meet work plan specifications and deadlines.
  </li>
  <li>
   International accounting qualification is desired: CA, ACCA, or CPA. Preferably CA.
  </li>
  <li>
   Fluent in English (Reading, Speaking and Writing). Preference will be given to Bilingual candidates (Arabic/English).
   <br/>
   <br/>
  </li>
 </ul>
</div>


Audit & Assurance | Senior Auditor | UAE

Mashreq

<div>
 Job Purpose
 <br/>
 <br/>
 - Executes the Audit Plan, by reviewable audit entity, for assigned businesses in accordance with Internal Audit standards, relevant government statutes and regulations and Mashreq Bank policies.
 <br/>
 - Delivers on time high quality audit reports and Internal Audit Action Plan Validation.
 <br/>
 - Proactively advances integrated auditing concepts, use of technology and data analytics.
 <br/>
 - Act as an Audit in Charge and lead a small to medium sized team of Internal Audit professionals and manages audit assignments within an agreed budget.
 <br/>
 - Possesses a broad and comprehensive understanding of different Internal Audit standards, policies and local regulations; applies a broad and comprehensive knowledge of high-risk areas including: Wholesale Credit Risk, Corporate &amp; Investment Banking products, and regulatory compliance.
 <br/>
 - Develops effective senior line management relationships and has a strong understanding of the businesses.
 <br/>
 - Applies an in-depth understanding of the inter-relationships of business and support units throughout the Bank and how they impact the overall control environment and the audit approach.
 <br/>
 - Uses excellent communication skills in order to influence a wide range of internal audiences including respective product or function. May negotiate internally often at higher levels on matters which will have a major impact on the area managed.
 <br/>
 - Demonstrates strong judgment, political astuteness, and sensitivity to cultural diversity.
 <br/>
 - Competent in assessing the risk environment and respond to changes therein through the annual risk assessment process.
 <br/>
 <br/>
 Key Result Areas
 <br/>
 <br/>
 - Supervise the assigned Off site /Onsite Review functions in an efficient, effective and proactive manner to achieve its objectives and to recognize and surface risks on the basis of timely identification of risks and early warning signals. Appropriate corrective actions to be recommended to the line in order to mitigate risk.
 <br/>
 <br/>
 - Fully comply with all systems and procedures, review criteria for selection of review parameters as established and modified from time to time, internal processes, turnaround time and credit policy in carrying out the job in a professional and efficient manner.
 <br/>
 <br/>
 - Ensure that review of credits both On and Offsite is carried out professionally and objectively to recognize and surface risk accurately and to assign appropriate risk ratings to the areas reviewed. Assigning of accurate risk ratings by business units and Risk Management in a timely manner is critical to the bank.
 <br/>
 <br/>
 - Review assigned units of the bank to recognize and surface risks and assign appropriate risk ratings in a timely manner, for appropriate corrective steps by the units or the relationship officers. Closely monitor closure of action plan items.
 <br/>
 <br/>
 - As an Audit in Charge, supervise and manage exams in a manner that all the review processes and approved review plans are complied with fully, risks in credits /processes are recognized and surfaced accurately and in a timely manner, correct risk ratings are assigned, results are effectively communicated to the unit and their buy in is obtained, in order to achieve the overall objectives of the review.
 <br/>
 <br/>
 - Provide suggestions and recommendations to the line to improve Processes in order to safeguard the banks interests.
 <br/>
 <br/>
 - Ensure that Reviews are conducted in an objective and professional manner so that there is no communication gap and results are largely accepted by the reviewees.
 <br/>
 <br/>
 - Provide on the job coaching and guidance, both offsite and during onsite exams
 <br/>
 <br/>
 - Establish good working relationships with the line to develop mutual understanding in order to facilitate communication and their acceptance of the review findings
 <br/>
 <br/>
 - Manage the monitoring of allocated business units to ensure early identification of risk through maintaining close contact with the units.
 <br/>
 <br/>
 <br/>
 Knowledge, Skills &amp; Experience
 <br/>
 <br/>
 - CA/CPA or equivalent.
 <br/>
 - Experience in Business Analytics and Risk Management is preferred.
 <br/>
 - Specific subject matter expertise and a solid understanding of Wholesale Credit Risk Management concepts.
 <br/>
 - High degree of lending (credit, analytical, judgmental) skills across various industries /countries.
 <br/>
 - Senior level experience in a related role with experience in Internal Audit and/or Wholesale Credit Risk environment, with proven abilities in taking responsibility for executing concurrently on a portfolio of high-quality deliverables to stakeholders according to strict timetables.
 <br/>
 - Demonstrates experience in managing teams and managing integrated internal audit and assurance delivery.
 <br/>
 - Effective negotiation skills, a proactive and 'no surprises' approach in communicating issues and strength in sustaining independent views.
 <br/>
 - This individual must be an articulate and effective communicator, both orally and in writing.
 <br/>
 - Strong interpersonal skills for interfacing with all levels of internal and external audit and management.
</div>


Senior Auditor - Wholesale Audit

Blue Cross Blue Shield

<div><h1 class="jobSectionHeader"><b>Summary
</b><br>
</h1>Audit and authorize reimbursement of specific medical stop loss claims. Effectively mitigate client medical stop loss claims and provide excellent customer service.
<h1 class="jobSectionHeader"><br>
<b>Description<br>
</b><br>
</h1><p><b>Position Purpose:
</b></p><p>Audit and authorize reimbursement of specific medical stop loss claims. Effectively mitigate client medical stop loss claims and provide excellent customer service.
</p><p></p><p><b>Logistics: </b>PACE Underwriters <b>&ndash; </b>one of BlueCross BlueShield's South Carolina subsidiary companies.
</p><p></p><p><b>Location: </b>This position is full-time (40 hours/week) Monday-Friday from <b>8:00am-4:30pm CST </b>and will be <b>fully remote or hybrid </b>if based near our Dallas office.
</p><p></p><p><b>What You&rsquo;ll Do:
</b></p><ul><li><p>Analyze and adjudicate stop loss claims and request appropriate reimbursement from carrier. Recognize cost mitigation opportunities. Authorize and release stop loss claims reimbursement checks at or below pre-set authority limits.
</p></li><li><p>Initiate claims investigations and vendor referrals. Interpret plan language, and identify experimental services and subrogation opportunities. Identify need for follow-up on pended claims and resolution.
</p></li><li><p>Communicate effectively with carriers, vendors, and management. Provide full claims service to both phone and written inquiries.
</p></li><li><p>Generate and maintain claims system reports to adjust reserves, identify pending and backlog claims, and provide renewal and enrollment/premium history.
</p></li><li><p>Develop new and review old stop loss claim forms. Assist with internal auditing of claims auditors, and training of claims auditors.
</p></li></ul><p></p><p><b>To Qualify for This Position, You'll Need the Following:
</b></p><ul><li><p><b>Required Education: </b>Associate's
</p></li><li><p><b>Required Work Experience: </b>6 years of managed care or reinsurance claims experience.
</p></li></ul><p></p><p><b>We Prefer That You Have the Following:
</b></p><ul><li><p><b>Preferred Skills and Abilities:
</b></p></li><li><p>Analyzes laws, regulations and contract language.
</p></li><li><p>Evaluates issues and develops recommendations.
</p></li><li><p>Handles confidential and sensitive information.
</p></li><li><p>Investigates assigned claims.
</p></li><li><p>Proposes claims adjustments and refunds.
</p></li><li><p>Works claims caseloads.
</p></li><li><p>Aggregate claims experience.
</p></li></ul><p></p><p><b>Our Comprehensive Benefits Package Includes the Following:
</b></p><p>We offer our employees great benefits and rewards. You will be eligible to participate in the benefits for the first of the month following 28 days of employment.
</p><ul><li><p>Subsidized health plans, dental and vision coverage
</p></li><li><p>401k retirement savings plan with company match
</p></li><li><p>Life Insurance
</p></li><li><p>Paid Time Off (PTO)
</p></li><li><p>On-site cafeterias and fitness centers in major locations
</p></li><li><p>Education Assistance
</p></li><li><p>Service Recognition
</p></li><li><p>National discounts to movies, theaters, zoos, theme parks and more
</p></li></ul><p></p><p><b>What We Can Do for You:
</b></p><p>We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.
</p><p></p><p><b>What To Expect Next:
</b></p><p>After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.
</p><p></p><p><b>Pay Range Information:
</b></p><p><b>Range Minimum
</b></p><p>$51,107.00
</p><p></p><p><b>Range Midpoint
</b></p><p>$74,418.00
</p><p></p><p><b>Range Maximum
</b></p><p>$97,729.00
</p><p></p><p><b>Pay Transparency Statement:
</b></p><p>Please note that this range represents the pay range for this and other positions that fall into this pay grade. Compensation decisions within the range will be dependent upon a variety of factors, including experience, geographic location, and internal equity.
</p><p></p><p><b>Equal Employment Opportunity Statement
</b></p><p></p><p>BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.
</p><p></p><p>We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.
</p><p></p><p>If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.com or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.
</p><p></p><p>We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information .
</p><p></p><p>Some states have required notifications. Here's more information .</p></div>

Auditor, Sr Stoploss Claim

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><b>Senior Claims Examiner &ndash; P&amp;C</b></div><br>
</div></div><br>
<div><div><div><b>Department:</b></div>
</div><div><div><b>Property &amp; Casualty</b></div><br>
</div></div><br>
<div><div><div><b>Reports To:</b></div>
</div><div><div><b>Claims Supervisor</b></div><br>
</div></div><br>
<div><div><div><b>FLSA Status:</b></div>
</div><div><div><b>Exempt in all state but California</b></div><br>
</div></div><br>
<div><div><div><b>Job Grade:</b></div>
</div><div><div><b>13</b></div><br>
</div></div><br>
<div><div><div><b>Career Ladder:</b></div>
</div><div><div><b>Next step in progression could include Complex Claims Examiner</b></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 a full-time Senior Claims Examiner to support our Property &amp; Casualty department. Employees who live less than 26 miles from the Concord, CA, Orange, CA, San Antonio, TX, or Lake Mary, FL offices are required to work once a week in the office. The remaining days can be worked remotely if technical requirements are met, and the employee resides in a state Athens operates in (includes CA, CT, FL, GA, ID, IL, MA, NY, NC, NJ, OH, OK, OR, PA, SC, TN, TX, VA and WV). Athens Program Insurance Services is the centerpiece of P&amp;C claims administration in the specialty programs marketplace. We are totally unique in that we focus only on commercial business specialization across multiple coverage lines. 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 through Friday at 37.5 hours per week.</div>
<div></div><div>The Senior Claims Examiner is responsible for the review, analysis and processing of complex claims, with emphasis on commercial property and residential property, business interruption, and inland marine claims within assigned authority limits and consistent with policy and legal requirements. These claims are typically high exposure, long term claims and will often entail litigation and coverage issues. The goal of this position is to ensure the delivery of quality service claims adjusting in full compliance with special claims handling obligations.</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><div>Advanced knowledge in the following areas:</div>
<div>1) claims handling concepts, practices and techniques, to include but not limited to coverage issues, and product line knowledge</div>
<div>2) functional knowledge of law and insurance regulations in various jurisdictions</div>
<div>3) demonstrated advanced verbal and written communications skills</div>
<div>4) demonstrated advanced analytical, decision making and negotiation skills</div>
<div></div><ul><li>Within prescribed settlement authority, establish appropriate reserves for both indemnity and expense and conduct reviews on a regular basis to ensure reserve adequacy. In matters exceeding settlement authority, should have the ability to recommend a specific reserve range, based on industry experience and the specific evidence secured in a specific claim investigation.</li>
<li>Fully evaluate losses, including expense budgeting and all available property limits (including sub-limits) to make recommendations and set proper reserves at appropriate levels for claims within and outside of client authority level. Demonstrate credibility with clients and other business professionals by discussing and explaining these recommendations.</li>
<li>Prepare comprehensive reports as required. Identify and communicate specific claim trends and account and/or policy issues to management.</li>
<li>Manage all processes requiring estimating, assessment, valuation, and applicable depreciation. Include interpretation and evaluation of applicable insurance contracts in the assessment process.</li>
<li>Possess familiarity with scoping, estimating and use of Xactimate and other valuation programs.</li>
<li>Document and manage claims (i.e.: record statements, update diaries, write reports) from inception to closure.</li>
<li>Ensure appropriateness of all payments</li>
<li>Coordinate and work with vendor services such as independent adjusting firms, contractors, consultants, forensic accountants, engineers, emergency repair, cleaning services and various replacement services to ensure prompt, equitable and appropriate resolution of all commercial property claims.</li>
<li>Large loss commercial claim handling and oversight experience. Facilitate communication between claimants, clients and brokers for resolution of claims.</li>
<li>Exchange information with clients, claimants, insurance brokers, inspectors, producers and account managers.</li>
<li>Superior customer service skills. Ability to recognize matters of urgency and act promptly and efficiently to address them.</li>
<li>Participate in client meetings, status conferences, file reviews and fully comply with client instructions for all levels of communication and notification.</li>
<li>Be aware of insurance fraud and the internal and external requirements of notification/reporting of potential fraudulent matters.</li>
<li>Keep the client involved in decision making as required and comply with escalation process for advance notification of serious losses.</li>
<li>Investigate, evaluate, and determine settlement value or denial of liability for severe to major-level claims</li>
<li>Within prescribed settlement authority for line of business, establish appropriate reserves for both indemnity and expense and reviews on a regular basis to ensure adequacy. Make recommendations to set reserves at an appropriate level for claims outside of authority level.</li>
<li>Prepare comprehensive reports as required. Identify and communicate specific claim trends and account and/or policy issues to management.</li>
<li>Manage the litigation process through the retention of counsel. Adhere to the line of business litigation guidelines to include budget, bill review and payment.</li>
<li>Ensure appropriateness of all payments</li>
<li>Capability to adjust large commercial property losses</li>
<li>Exchange information with clients, claimants, insurance brokers, inspectors producers and account managers</li>
<li>Assist in training of new employees</li>
<li>Provide training and daily guidance to other examiners</li>
<li>Some oversight of less experienced examiners and claims assistants</li>
<li>May fill-in for supervisor if necessary</li>
<li>Attend meetings and educational seminars for professional development and to maintain required licenses</li>
<li>Coordinate and work with a vendor services such as contractors, emergency repair, cleaning services and various replacement services.</li>
<li>Participate and/or conduct department meetings</li>
<li>Present company abilities in new client meetings</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>
<div></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>Relies on extensive experience and judgment to plan and accomplish goals with a minimum 8-10 years of complex/major property claims experience including proficiency in investigation and resolution of severe to major casualty claims</li>
<li>Must possess a license from your domiciled (state you live in or designated home state) state and a minimum of one license in any of the following states: NY, TX or FL
<ul><li>Additional State Adjuster License(s) may be required within 180 days</li>
<li>Maintain licenses and continuing education requirements in all states.</li>
</ul></li><li>Experience with property and casualty insurance policies, insurance tort laws, codes and procedures</li>
<li>Knowledge of contractual/policy law and commercial property insurance policies. Experience in reviewing Condo By-Laws and Condo Rules and Regulations</li>
<li>Proficiency in investigation and resolution of moderate to major property claims. Understands principals of co-insurance and replacement cost evaluations</li>
<li>Understanding of medical, legal terminology and liability concepts</li>
<li>Time Management and project management skills</li>
<li>Negotiation skills</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></div><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>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><div></div>

Senior Property Claims Examiner

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