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Oversees and directs the management of the claims function to include review and approval of claims. Directs the implementation and ongoing maintenance of claims handling systems, policies, and procedures. Typically requires a college degree and five or more years of claims management experience.: Monitors departmental operations to ensure compliance with regulatory agencies as well as contractual obligations. Performs regular data analysis of claims payment reports to identify variances so that areas of focus may be identified and resources may be appropriately deployed. Provides support on complex claims issues. Prepares and manages the departmental budget and manages expenses. Hires, develops, and motivates a qualified claims processing staff.

Medical Claims Review Manager

Manages the medical claims review staff to ensure process improvement and quality in claims review. This position typically requires a Bachelor’s degree with five years of medical review experience. This position may require a nursing degree.: Manages the medical claims review staff to ensure process improvement and quality in claims review. Translates benefit plan language (Summary Plan Descriptions) into standard review program procedures. Interfaces with clients to conduct/manage random sample reviews to determine medical claims processing accuracy and timeliness. Works with clients to coordinate operational reviews to assess administrative processes and controls. Reviews company claims, eligibility, provider, and medical management systems to identify issues affecting quality and productivity. Documents findings and write follow-up reports. Provides planning, organizing and budgeting for the department. Develops, administers and reports service quality indicators for each team under supervision. Recommends and implements innovative strategies to retain members, contain medical costs and improve efficiency. Hires, trains, coaches, counsels and evaluates performance of direct reports. This position typically requires a Bachelor’s degree with five years of medical review experience. This position may require a nursing degree.

Claims Manager

Oversees claims management to ensure timely, accurate handling of claims, quality claims services, and appropriate resolution of claim discrepancies. Supervises claims staff. : Manages, reviews, and resolves claims, including determining course of action, developing arguments and addressing claimants' rebuttals, conducting preliminary negotiations, and preparing and issuing notices to claimants and other third-parties. Manages administrative, financial, accounting, and reporting functions for claims. Assists in overall case resolution strategies, settlements, and litigation support. Authorizes appropriate payment or refers claims to investigators for further review. Analyzes and identifies trends and provides reports as necessary. Provides input for forecasting and planning activities. Generates risk analysis reports for management. Monitors and participates in quality control and reviews. Manages and monitors all high-exposure and complex files. Oversees operational management of the Claims Department, including overall productivity, efficiency, and accuracy. Provides expertise or general claims support to teams in reviewing, researching, investigating, negotiating, processing, and adjusting claims. Directs claims staff hiring, oversight, coaching, and training.

Claims Quality Audit Manager

Supervises and facilitates the coordination and scheduling of all external claims audits conducted by customers, audit firms, external vendors, and regulators. Assists in the preparation of audits and management of the audit process. : Notifies appropriate parties of the audit and schedules entrance and exit conferences. Develops tools to assist staff in effectively coordinating audits and holds staff meetings as needed. Reviews customer contracts for audit rights, and prepares necessary audit confidentiality agreements and Par Plan addendum agreements. Supervises the obtaining and reviewing of claim samples and documentation. Ensure all HIPAA requirements applicable to the job are met. Directs and oversees analysis of requested data in order to minimize organization's risks. Ensures data integrity. Assures that auditors have a positive experience. Reviews findings and responses for adequacy and appropriateness. Reviews draft and final audit reports from auditors. Prepares responses to report findings. May travel to other claims audit locations as needed.

Claims Quality Audit Director

Directs the Claims Quality Audit Department and provides managerial oversight to employees engaged in claims auditing and training. Approves department policies, practices, and procedures to ensure identification of claims processing errors. Provides planning, organizing, and budgeting for the department. Typically requires a college degree in a related field and an in-depth understanding of claims auditing.: Provides oversight of departmental training and auditing activities. Monitors departmental operations to ensure compliance with regulatory agencies and contractual obligations. Develops strategic initiatives and transforms initiatives into action plans. Hires, trains, and motivates a qualified management staff. Oversees the development of training programs that are targeted toward error reduction and decision quality in claims processing. Analyzes audit and training reports to determine department effectiveness.

Claims Quality Audit Supervisor

Supervises employees engaged in claims auditing and training. Implements claim auditing department policies, practices, and procedures to ensure identification of claims processing errors. Typically requires prior experience as a Claims Processor or Adjudicator and an in-depth understanding of claims auditing.: Supervises auditing activities by monitoring weekly backlogs, distributing audit assignments based on work loads, and reviewing and responding to audit inquiries. Responds to error rebuttals from Claims Processors or Adjudicators. Assists in hiring, training, coaching, and evaluating performance of assigned staff. Contributes to the development of training programs that are targeted toward error reduction and decision quality in claims processing. Monitors training programs to evaluate effectiveness.

Claims Supervisor

Supervises and coordinates activities of workers engaged in examining insurance claims for payment in claims division of insurance company. Ensures all claims eligible or ineligible for payment conform to quality, production standards and specifications. A bachelor's degree with four years of claims examining/auditing experience may be required to fulfill the requirements of this position.: Ensures evaluation of all claims through determination of types and amounts of benefit payable. Ensures/oversees documenting of provider claims/billing forms to support payment/decisions. Ensures claims processing is consistent with applicable policies, procedures, and department guidelines. Supervises maintenance of claims records. Reviews appeals and complaints that Examiners are unable to resolve. Analyzes and approves insurance claims. Conducts personal interviews with claimants to explain procedure for filing claims. Submits statement of claim liabilities to actuarial department for review. Informs departmental supervisors on claims status. Interprets company policy to employees and enforces company policy and practices. Reviews and analyzes processes, procedures, and workflows to identify opportunities for process improvement and efficiency. Prepares regular periodic reports, and reviews/monitors system reports to ensure adherence to corporate and regulatory standards within established guidelines. May participate in the specialized training and handling of complex claim situations and projects requiring advanced claim knowledge and experience, as delegated by Claims Manager and/or Director. May recruit, hire, train staff, evaluate employee performance, and recommend or initiate promotions, transfers, and disciplinary action.

Medical Claims Review Nurse

Resolves, audits, and processes claims for clinically related issues to ensure accuracy of claims payment, supporting the Claims Administration Department. Maintains contact with community hospitals and providers, reviewing, processing, and auditing claims for payment and appropriateness of charges and pursues adjustments as warranted. Typically requires licensure as a Registered Nurse and at least one year of experience in utilization review or a managed care setting.: Screens, audits, and processes claims of specific criteria for appropriate payment. Establishes effective ongoing relationships with community hospitals and providers. Participates in educational, provider relations, and contracting meetings with providers to address medical claims payment issues. Visits the providers as necessary to compare billed charges to the medical record. Provides support to the Accounting Department in determining financial liability for out-of-plan medical services. Performs special projects, reconciliations, research, and analysis relating to the utilization and cost of medical services. Works closely with various departments to coordinate the flow of information involving payment of medical bills and analyses of financial liability. Ensures compliance with contractual obligations on claims payments. Documents findings and writes follow-up reports. Recommends and implements innovative strategies to retain members, contain medical costs, and improve efficiency.

Disability Work Compensation Claims Specialist

Reviews, analyzes, investigates, makes liability decisions and approves the release of benefit payments up to authorized levels on initial, continued and reopened claims.: Independently reviews simple to complex claims for adjudication purposes. Evaluates new and ongoing claims to determine liability according to contract provisions, medical evidence, and vocational evidence and duration contract guidelines. Performs periodic follow-up to determine continuing existence of a disabling condition. Analyzes documentation and summarizes data gathered from a variety of sources. Responds to telephone and written inquiries from claimants, attorneys, physicians and policy holders. Updates and maintains accurate records. This position typically requires knowledge of case law and state worker’s compensation laws. A minimum of three years of claims adjudication experience is typically required.

Claims Adjudicator (Entry)

Adjudicates or processes health and dental benefit claims for payment.: Under direct supervision, reviews and adjudicates claims. Determines whether to return, suspend, deny or pay claims within established policies and procedures. Compares claim application and/or provider statement with plan file and other records to evaluate completeness and validity of claim. Analyzes and answers inquiries regarding claim adjudication, including method of payment, co-pay or deductible amounts, and or reason for denial. Requests information from internal or outside sources to ascertain completeness and validity of claim including coordination of benefits information. Compares data on claim application, death certificate, or physician's statement with policy file and other company records to ascertain validity and to adjudicate the claim. Routes claims requiring additional information or high-level decision-making. Researches claims as needed. Communicates with agents and claimants to correct errors or omissions on claim forms. This is an entry level position and typically does not require previous claims processing experience.

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