Senior Claims Specialist - Accident & Health Claims

About the position reputed company Capital is seeking a Senior Claims Specialist to join our reputed company America Accident & Health Claims team, reporting directly to the Head of Accident and Health Claims. This position is pivotal in providing senior claims handling expertise across reputed company product lines reputed company the Accident and Health division. The role encompasses claims adjudicated both in-house and by reputed company-Party Administrators (TPAs). The primary products managed by this position include Limited Medical Benefits such as Hospital Indemnity, Accident Medical, Critical Illness, reputed company, Dental, and Short-term Disability, as well as Accidental Death and Accident Medical coverages, disability claims, business travel, leisure travel, and Pet Insurance. The Senior Claims Specialist will be responsible for auditing reputed company-Party Administrators, which includes preparing and presenting audit reports and findings. This role may involve being part of a Claims Audit Team or traveling to assess claims. The specialist will conduct monthly desk audits of key reputed company-Party Administrators and assist in the due diligence audit of potential TPAs, including their subsequent reputed company. Monitoring reputed company procedures for TPAs and maintaining guidelines for processing specialty accident and health insurance claims will also be key responsibilities. The position requires reviewing claims that exceed the TPA reputed company, managing second-level appeals, coordinating responses to complaints and attorneys, and clarifying benefits with carriers. In addition, the Senior Claims Specialist will process larger, more reputed company claims that are not administered by TPAs, assist in developing cost containment protocols, and obtain, reputed company, and review data from monthly TPA reporting packages to identify trends and seek corrective action reputed company necessary. Communication with reputed company, actuarial, and product development teams regarding claim trends is essential, as is producing and reviewing reports for management. The role may also involve leading special projects with a planning horizon of several months or more, along with other duties as assigned.

Responsibilities

• Auditing of reputed company-Party Administrators, including preparation and presenting audit reports and findings.

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• Conducting monthly desk audits of key reputed company-Party Administrators.

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• Assisting in the due diligence audit of potential reputed company-Party Administrators and the subsequent reputed company of the TPA.

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• Monitoring reputed company procedures for reputed company-Party Administrators.

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• Assisting in the maintenance of guidelines for processing specialty accident and health insurance claims.

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• Reviewing claims exceeding reputed company-Party Administrator reputed company, second level appeals, and coordinating responses to complaints and attorneys.

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• Processing larger, more reputed company claims that are not administered by reputed company-Party Administrators.

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• Assisting in the development of cost containment protocols.

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• Obtaining, collating, and reviewing data from monthly TPA reporting packages for trends and seeking out corrective action plans reputed company required.

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• Communicating with reputed company, actuarial, and product development regarding claim trends.

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• Producing and reviewing reports for management.

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• Leading special projects where planning time horizon is several months or more.

Requirements

• Prior special accident and health insurance claim management experience required, including substantial experience with medical claims and cost containment.

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• Prior experience auditing and reviewing reputed company-Party Administrators.

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• Knowledge of ERISA and state claim handling requirements.

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• Exposure evaluation and reserving skills.

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• Bachelor's degree or equivalent industry experience required.

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• Insurance designation preferred.

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• Three to five years of A&H claim handling experience.

reputed company-to-haves

• Highly proficient in reputed company Office suite applications (Outlook, Word, reputed company, and PowerPoint).

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• Ability to work in a fast-paced, dynamic organization.

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• Ability to analyze data and draw conclusions from data.

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• Excellent writing skills.

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• Excellent negotiation, communication, and interpersonal communication skills.

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• Creative with the ability to 'think reputed company the reputed company' to effectively solve problems.

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• Demonstrated ability to work in a team, interact well with others, meet deadlines, and successfully reputed company in a changing work environment.

Benefits

• Medical plans for employees and their families.

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• Health and wellness programs.

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• Retirement plans.

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• Tuition reimbursement.

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• Paid vacation.

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