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field_job_experience

job_organization_name

city

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<h3>Job Description</h3>
Job Description
Healthcare quality is declining and soaring costs are crushing American families and businesses. At Garner, we've developed a revolutionary approach to evaluating doctor performance and a unique incentive model that's reshaping the healthcare economy to ensure everyone can afford high quality care. By providing organizations relief from surging healthcare costs, we've experienced rapid adoption in the market and have more than doubled our revenue annually over the last 5 years, becoming the fastest growing company in our space. To support our continued growth, we're expanding our team by over 50% each year, seeking exceptional talent to shape our unique, award winning culture (for example, USA Today Top Workplaces 2025) designed to cultivate teamwork, trust, autonomy, exceptional results, and individual growth that creates an inflection point in your career.
About the role:
We're looking for a full-time Claims Associate to join our high-growth Claims team. 
The Claims team is responsible for ensuring that our members' claims get paid accurately and quickly. We do this by evaluating claim submissions and supporting members through the process. Ultimately, we strive to deliver a best-in-class "claims experience" for every member.
In this role, you will be on the front line of our team, evaluating claim submissions and interacting with members via chat, email, and phone to help them navigate the claims process. You will become an expert on Garner's product, claims processing standards, and the needs of our members. The Claims team is a key touchpoint for our members, so you should be passionate about helping people and a proactive problem solver.
To ensure that we can respond to issues in real time, Associates have some schedule requirements. Current operations run weekdays during East Coast hours of 8am to 10pm, though that may change in the future as needs dictate. 
This position is fully remote.
What you will do:
<ul>
<li>Evaluate claims to determine whether they qualify for reimbursement</li>
<li>Deliver exceptional service to our members via phone, chat, and email, offering education and guidance to help them navigate the Garner claims process</li>
<li>Follow documented best practices for handling claims and communicating with members; suggesting process improvements as you identify them</li>
<li>Manage and organize workload using Garner's platform and tools, including Zendesk and G Suite</li>
<li>Achieve pre-defined goals for efficiency, responsiveness, and quality</li>
<li>Triage and escalate complex and urgent member situations</li>
<li>Retain detail-oriented working knowledge of Garner processes and healthcare billing practices</li>
<li>Relay member feedback to leadership teams to improve Garner's solution</li>
</ul>
What you will bring to the team:
<ul>
<li>A passion for helping people solve their problems with an ability to think creatively and empathetically</li>
<li>Experience working in a customer-facing or operations environment with demonstrated experience staying calm under pressure</li>
<li>Excellent written and verbal communication skills</li>
<li>A high level of detail- and process-orientation, digital organization, and resourcefulness</li>
<li>A desire to work in a rapidly evolving startup environment; comfortable with some ambiguity</li>
<li>A desire to be a part of our mission to improve the healthcare system</li>
<li>A quiet and distraction-free work environment with a reliable internet connection (ability to hard wire if needed strongly preferred)</li>
<li>A bachelor's degree is preferred but not required</li>
</ul>
Compensation Transparency:
The base compensation for this position is: $18-$22/hr. This position will also include a $0.50 additional hourly bump for English/Spanish bilingual candidates. Individual compensation for this role will depend on various factors, including qualifications, skills, and applicable laws. In addition to base compensation, this role is eligible to participate in our equity incentive and competitive benefits plans, including but not limited to: flexible PTO, Medical/Dental/Vision plan options, 401(k) with company match, flexible spending accounts, Teladoc Health and more.
Fraud and Security Notice: 
Please be aware of recent job scam attempts. Our recruiters use getgarner.com email domain exclusively. If you have been contacted by someone claiming to be a Garner recruiter or a hiring manager from a different domain about a potential job, please report it to law enforcement here and to <a href="mailto:candidateprotection@getgarner.com" target="_blank">candidateprotection@getgarner.com</a>.
Equal Employment Opportunity: Garner Health is proud to be an Equal Employment Opportunity employer and values diversity in the workplace. We do not discriminate based upon race, religion, color, national origin, sex (including pregnancy, childbirth, reproductive health decisions, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, genetic information, political views or activity, or other applicable legally protected characteristics.
Garner Health is committed to providing accommodations for qualified individuals with disabilities in our recruiting process. If you need assistance or an accommodation due to a disability, you may contact us at <a href="mailto:talent@getgarner.com" target="_blank">talent@getgarner.com</a>.

Claims Associate

<h3>Job Description</h3>
Job Description
**This role is onsite at our Roslyn, NY or Rochester, NY office, with the option for a hybrid schedule after the training period. **
General Summary: A Claims Specialist will utilize their experience in medical liability claim handling to investigate, evaluate, and resolve high exposure claims while demonstrating a strong commitment to exceptional client service. 
Essential Duties &amp; Responsibilities:
<ul>
<li>Follow standard claims protocols for documentation, coverage verification, and file management</li>
<li>Maintain accurate and organized claims files, suggesting improvements as necessary</li>
<li>Assist in client relationship management, collaborate with underwriting on marketing</li>
<li>Investigate and document most significant exposures, setting appropriate indemnity and expense reserves</li>
<li>Develop resolutions strategy and participate in negotiations to bring matters to a close </li>
<li>Attend trials and mediations when necessary</li>
<li>Adhere to industry Best Practices for effective claim management</li>
<li>Mentor staff through formal and informal training and development; demonstrate strong technical knowledge to guide and support less experienced claims professionals</li>
<li>Ensure exceptional data integrity</li>
<li>Actively manage defense council and partner on litigation strategy</li>
<li>Proactive communication with insureds, other departments and claim leadership</li>
<li>Perform additional duties and responsibilities as assigned</li>
</ul>
Education &amp; Qualifications:
<ul>
<li>Bachelor’s degree or JD required </li>
<li>Five years’ claims handling experience required; medical professional liability preferred </li>
<li>NY adjusters license required within the first 6 - 12 months of employment</li>
<li>Strong analytical and problem-solving skills with attention to detail</li>
<li>Demonstrate solid and concise business writing proficiency</li>
<li>Exhibit strong oral communication skills to include presenting information clearly and effectively to diverse audiences</li>
<li>Ability to work independently as well as collaboratively within a team. Set a strong example for less experienced colleagues </li>
<li>Strong ethical judgement and a commitment to maintaining confidentiality</li>
<li>Must be able to work on site</li>
<li>Travel required as needed; may include overnight travel </li>
</ul>
The actual compensation for this position will be determined by experience and other factors permitted by law.

Claims Specialist

<h3>Job Description</h3>
Job DescriptionJoin a company that values integrity, teamwork, and exceptional service with over 100 years of service in the Pittsburgh area! As the Claims Adjuster, you’ll investigate property and cargo claims, determine validity, and reach fair, timely resolutions. You’ll work with customers, carriers, insurance companies, and internal teams to reduce claim frequency and ensure customer satisfaction. What You’ll Do:
<ul>
<li>Investigate property and cargo claims and determine equitable resolutions</li>
</ul>
<ul>
<li>Prepare and maintain reports on open claims, aging, and chargebacks</li>
</ul>
<ul>
<li>Negotiating settlements with insurance companies, shippers/customers</li>
<li>Subrogate with carriers and insurers for reimbursement</li>
</ul>
<ul>
<li>Communicate professionally with customers and co-workers</li>
</ul>
<ul>
<li>Complete all work safely, accurately, and on time</li>
</ul>
What We’re Looking For:
<ul>
<li>Detail-oriented, analytical problem solver</li>
</ul>
<ul>
<li>Excellent communication and organizational skills</li>
</ul>
<ul>
<li>Positive attitude and commitment to our Mission, Vision &amp; Values</li>
</ul>
Be part of a trusted team that keeps people moving with care and professionalism. Apply today to join South Hills Movers! Claims property cargo analyst adjuster resolution claim transportation specialist processor &nbsp;
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Claims Adjuster

<h3>Job Description</h3>
Job Description
Looking to hire an associate attorney with 3+ years of insurance coverage and/or litigation experience. Great opportunity to work in-house with an insurance carrier handling MPL and PL claims.
$120-125k base salary, plus bonus
3 days per week in office

<h3>Job Description</h3>
Job Description
The Property and Cargo Claim Adjuster is responsible for managing claims involving cargo loss, property damage, and auto damage across 48 states within a flatbed trucking operation. This desk-based role requires strong analytical skills, attention to detail, and the ability to resolve claims efficiently and in compliance with company policies and regulatory standards. Experience with bodily injury is a plus. The position is based in our Tulsa office.
Essential Duties and Responsibilities:
Claims Investigation &amp; Evaluation
<ul>
<li>Handle cargo, property, and auto damage claims from intake through resolution.</li>
<li>Review documentation, photographs, driver statements, and other evidence to determine liability and damages.</li>
<li>Manage the investigation process by determining what outside resources (e.g., appraisers, adjusters, forensic experts) are needed for each incident.</li>
<li>Communicate effectively with drivers, vendors, first responders, customers, and third-party claimants.</li>
</ul>
Claim Resolution
<ul>
<li>Negotiate settlements with claimants, vendors, and third parties.</li>
<li>Identify and pursue subrogation and recovery opportunities.</li>
<li>Use specific industry, company, and case knowledge to reach the best agreement for the operational success of Melton.</li>
</ul>
Documentation &amp; Compliance
<ul>
<li>Maintain accurate and detailed claim files, notes, and reports.</li>
<li>Ensure compliance with federal, state, and industry regulations, including DOT and FMCSA standards.</li>
<li>Stay current on regulatory changes and industry best practices.</li>
</ul>
Internal Collaboration
<ul>
<li>Partner with Safety, Risk Management, Dispatch, and Operations to support investigations and loss prevention.</li>
<li>Provide insights and recommendations to improve claims processes and reduce exposure.</li>
</ul>
Qualifications:
-Must have an active Claims Adjusters license and be willing to complete continuing education and training.
- Proven experience as a Claims Adjuster, property, cargo, and bodily injury experience preferred.
- Knowledge of the trucking and logistics industry, including relevant regulations and compliance requirements.
- Strong analytical and decision-making skills, with the ability to manage complex claims.
- Excellent negotiation and interpersonal skills, with the ability to communicate effectively with various stakeholders.
- Proficient in claims management software and Microsoft Office Suite.
-High school diploma required, college degree preferred.
-English/Spanish bilingual preferred but not required.
Physical Demands: It is necessary to talk, hear, sit, walk, type, and write. It is occasionally necessary to lift up to 25 lbs.

<h3>Job Description</h3>
Job Description
 
Role: Claims Analyst
Organization: Edenbridge PACE at Skyland 
Location: Washington, DC SE
Status: Full-time
Mission: To allow frail elderly people to age in the location of their choosing and continue to lead connected, meaningful lives
JOB SUMMARY
The Claims Analyst reviews, processes and analyzes healthcare claims to determine their validity and accuracy. They assess damages, verify policy coverage and ensure compliance with regulations and company procedures. Effective communication, problem-solving and attention to detail are crucial for this role.
 
ESSENTIAL DUTIES AND RESPONSIBILITIES
 
<ul>
<li>
Reviews submitted claims for accuracy, completeness and adherence to policy terms and legal requirements. 
</li>
<li>
Analyzes claim data to identify trends, patterns, and potential irregularities. 
</li>
<li>
Communicates with stakeholders to gather information, explain decisions, and resolve issues. 
</li>
<li>
Investigates potential fraudulent claims and gathering supporting evidence. 
</li>
<li>
Makes informed decisions on claim validity and determining appropriate compensation. 
</li>
<li>
Maintains accurate and detailed records of claims processing and outcomes. 
</li>
<li>
Ensures adherence to relevant regulations and company policies. 
</li>
<li>
Develop and maintain positive relationships with the network of providers through ongoing 
</li>
</ul>
communication and by providing feedback
<ul>
<li>
Performs other duties as required.
</li>
</ul>
 
QUALIFICATIONS
Education and Experience:
<ul>
<li>
High School Diploma. Associate’s Degree preferred.
</li>
<li>
1-3 years of experience in data analysis in a customer service environment within the healthcare insurance industry preferred.
</li>
<li>
Experience analyzing data, identifying discrepancies and making informed decisions.
</li>
</ul>
Skills and Competencies:
<ul>
<li>
Able to clearly explain complex information, both verbally and in writing. 
</li>
<li>
Able to identify and resolve issues related to claims processing. 
</li>
<li>
Strong attention to detail to ensure accuracy in claim review and data entry. 
</li>
<li>
Knowledge of Insurance/Healthcare, including understanding policy terms, coverage, and relevant regulations. 
</li>
<li>
Exceptional customer service skills.
</li>
</ul>
 
 
Learn more at: 
edenbridgepace.com/dc

Claims Analyst

<h3>Job Description</h3>
Job Description
Oversee all daily functions of the Claims Department Liaise between Upper Management and Claims Department Essential Duties and Responsibilities:
<ul>
<li>Strive to provide excellent customer service to our associates, agents, adjusters, attorneys and all who require our assistance</li>
<li>Hiring and Training of claims department staff</li>
<li>Advise CEO/Underwriter/Branch Manager of any potentially large exposures and/or any problems that may arise beyond the normal everyday occurrences</li>
<li>Report all E&amp;O exposures to CEO with full details and claim file</li>
<li>Review problem files: ie:&nbsp; Insured’s disputing denials, complaints filed with the</li>
<li>Insurance Department and/or&nbsp;London Complaint Department</li>
<li>Recommend and assign attorneys as appointed by London to defend losses or request coverage opinions.&nbsp; </li>
<li>Keep all parties involved updated </li>
<li>Direct claims staff with coverage issues</li>
<li>Review daily checks prepared by the claims team</li>
<li>Work with accounting to determine availability of funds for weekly claim payments</li>
<li>Handle incoming phone calls </li>
<li>Review all incoming mail and distribute accordingly for processing</li>
<li>Prepare yearly staff performance evaluations and goal setting for claim staff</li>
<li>Encourage the claims team to pursue continuing education and recommend training when needed</li>
<li>Run monthly Bordereaux reports and work with accounting to tie out payments</li>
<li>Perform Peer Reviews for the London contracts</li>
<li>Review adjuster performance and keep records of&nbsp; E&amp;O certificates.&nbsp; </li>
<li>Interview adjusting firms to determine if they are compatible with our needs.</li>
<li>Review London contracts to be sure we are in compliance with the contracts Review adjuster panels for each contract.</li>
<li>Prepare our claim files for annual audits</li>
<li>Comply with Subpoenas served on Jimcor, document production</li>
</ul>
 Qualifications/Requirements:
<ul>
<li>Strong knowledge of standard property and casualty insurance statutes, regulations and practices; casualty/liability claims adjusting including analyzing and coordinating disposition of claims</li>
<li>Good supervisory practices</li>
<li>Good analytical skills for interpreting laws and regulations as a basis for decision-making</li>
</ul>
We offer a total compensation package which includes salary (80k-95k) plus a full comprehensive&nbsp;benefits package. Package includes Paid Time Off Days, Paid Holidays, Hybrid Work Schedule, Retirement Plan with Employer Match, 100% Single Employer Paid Medical, Dental, Vision, Life Insurance, Education Assistance,&nbsp; Various Voluntary Benefits, Wellness Program Including Mental Health Support and an Employee Assistance Program (EAP) and More.&nbsp;
Visit Us On LinkedIn: <a href="https://www.linkedin.com/company/jimcor-agencies/" target="_blank">https://www.linkedin.com/company/jimcor-agencies/</a>
View All Openings: <a href="https://www.jimcor.com/join-our-team" target="_blank">https://www.jimcor.com/join-our-team</a>
Website: <a href="http://www.jimcor.com" target="_blank">www.jimcor.com</a>
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Claims Manager

<h3>Job Description</h3>
Job DescriptionDescriptionAbout the Company A well-established public adjusting firm is seeking motivated Public Adjuster Solicitors to join its growing team.&nbsp; This firm specializes in advocating for policyholders and ensuring they receive fair settlements for property damage claims.&nbsp; As the demand for expert claims assistance grows, we are looking for ambitious sales professionals who can build strong client relationships and drive business growth. Position Overview The Public Adjuster Solicitor serves as the first point of contact for homeowners and businesses seeking assistance with insurance claims.&nbsp; This role involves prospecting, educating potential clients, and generating leads while working under the supervision of a licensed public adjuster.&nbsp; It’s an ideal position for sales-driven individuals who enjoy helping clients navigate insurance claims and maximizing their settlements. Key Responsibilities
<ul>
<li>Identify and engage potential clients, including homeowners, contractors, and business owners.</li>
<li>Educate prospective clients on public adjusting services and the benefits of professional claims representation.</li>
<li>Solicit qualified leads furnished from our office and networking through referrals, and direct outreach.</li>
<li>Conduct initial consultations to assess client needs and determine claim eligibility.</li>
<li>Work closely with management and licensed public adjusters to transition leads into active claims.</li>
<li>Provide ongoing client support and maintain strong relationships.</li>
<li>Present and sell our service to obtain new clients for the firm.</li>
<li>Respond quickly to disaster scenes.</li>
<li>Follow-up on all leads and assignments.</li>
</ul>
 Skills, Knowledge and Expertise
<ul>
<li>2+ years of sales experience, preferable in insurance, real estate, restoration, or a related field.</li>
<li>Strong ability to generate leads, build relationships, and close sales.</li>
<li>Public Adjuster Solicitor license preferred (or willingness to obtain).</li>
<li>Self-motivated with strong communication and negotiation skills.</li>
<li>Must have a valid driver’s license and reliable transportation.</li>
<li>Business-like professional appearance.</li>
<li>Ability to close on first call.</li>
<li>Have in home or face to face sales experience.</li>
<li>Work requires to be on-call.</li>
</ul>
 Benefits
<ul>
<li>High earing potential with competitive commission and performance-based bonuses.</li>
<li>Extensive training and mentorship to help you succeed in this role.</li>
<li>Flexible work schedule with the ability to manage your own territory.</li>
<li>A team-oriented culture with strong leadership and professional development support.</li>
</ul>
 If you are a motivated sales professional looking for a rewarding career with uncapped earnings potential, apply today and start making a difference for policyholders in Pennsylvania! Competitive Advantages 
<ul>
<li>One of the oldest and largest public adjusting firms in Pennsylvania</li>
<li>Firm provides unlimited quality leads and informational support.</li>
<li>Excellent reputation.</li>
<li>Large in-house support staff with experience in construction, personal property and loss of business claims.</li>
<li>Experience to handle high-end large and complex losses for both homeowners and business owners.&nbsp;</li>
</ul>

<h3>Job Description</h3>
Job Description
The Claims Specialist manages within company best practices lower-level, non-complex and non-problematic workers’ compensation claims within delegated limited authority to best possible outcome, under the direct supervision of a senior claims professional, supporting the goals of claims department and of CorVel.
 This is a remote role.
ESSENTIAL FUNCTIONS &amp; RESPONSIBILITIES:
<ul>
<li>Receives claims, confirms policy coverage and acknowledgment of the claim</li>
<li>Determines validity and compensability of the claim</li>
<li>Establishes reserves and authorizes payments within reserving authority limits</li>
<li>Manages non-complex and non-problematic medical only claims and minor lost-time workers’ compensation claims under close supervision</li>
<li>Communicates claim status with the customer, claimant and client</li>
<li>Adheres to client and carrier guidelines and participates in claims review as needed</li>
<li>Assists other claims professionals with more complex or problematic claims as necessary</li>
<li>Additional duties as assigned</li>
</ul>
KNOWLEDGE &amp; SKILLS: 
<ul>
<li>Excellent written and verbal communication skills</li>
<li>Ability to learn rapidly to develop knowledge and understanding of claims practice</li>
<li>Ability to identify, analyze and solve problems</li>
<li>Computer proficiency and technical aptitude with the ability to utilize Microsoft Office including Excel spreadsheets</li>
<li>Strong interpersonal, time management and organizational skills</li>
<li>Ability to meet or exceed performance competencies</li>
<li>Ability to work both independently and within a team environment</li>
</ul>
EDUCATION &amp; EXPERIENCE: 
<ul>
<li>Bachelor's degree or a combination of education and related experience</li>
<li>Minimum of 1 year of industry experience and claims management preferred</li>
<li>State Certification as an Experienced Examiner</li>
</ul>
PAY RANGE:
CorVel uses a market based approach to pay and our salary ranges may vary depending on your location. Pay rates are established taking into account the following factors: federal, state, and local minimum wage requirements, the geographic location differential, job-related skills, experience, qualifications, internal employee equity, and market conditions. Our ranges may be modified at any time.
For leveled roles (I, II, III, Senior, Lead, etc.) new hires may be slotted into a different level, either up or down, based on assessment during interview process taking into consideration experience, qualifications, and overall fit for the role. The level may impact the salary range and these adjustments would be clarified during the offer process.
Pay Range: $51,807 - $83,551 
A list of our benefit offerings can be found on our CorVel website: CorVel Careers | Opportunities in Risk Management
In general, our opportunities will be posted for up to 1 year from date of posting, or until we have selected candidate(s) to fulfill the opening, whichever comes first.
ABOUT CORVEL
CorVel, a certified Great Place to Work® Company, is a national provider of industry-leading risk management solutions for the workers’ compensation, auto, health and disability management industries. CorVel was founded in 1987 and has been publicly traded on the NASDAQ stock exchange since 1991. Our continual investment in human capital and technology enable us to deliver the most innovative and integrated solutions to our clients. We are a stable and growing company with a strong, supportive culture and plenty of career advancement opportunities. Over 4,000 people working across the United States embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!). 
A comprehensive benefits package is available for full-time regular employees and includes Medical (HDHP) w/Pharmacy, Dental, Vision, Long Term Disability, Health Savings Account, Flexible Spending Account Options, Life Insurance, Accident Insurance, Critical Illness Insurance, Pre-paid Legal Insurance, Parking and Transit FSA accounts, 401K, ROTH 401K, and paid time off.
CorVel is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.
#LI-Remote

<h3>Job Description</h3>
Job Description
Reporting to Supervisor, Claims Processing, the Claims Specialist is responsible for complex claims processing, Provider Dispute Resolution (PDR) processing, recoupments, claims adjustments, and research. Must meet qualitative and quantitative standards established for this position. You will maintain Claims Department's inventory, handle claims trouble shooter reports, and respond to first level escalations. Also, this position must stay informed about Claims and PDR processing procedures, and assist Claims Management on audits, project user acceptance tests, and special projects.
Please note that while SFHP supports a hybrid work environment, the Claims Specialist is not required to meet the minimum in-office requirement of 4x/month but is required to attend company meetings and other in-person events at Supervisor's discretion.
Salary: $33.65 - $38.94 per hour
WHAT YOU WILL DO:
<ul>
<li>Keep the department's claim and PDR inventory current and clear edit queues by processing claims and PDRs according to regulatory requirements, eligibility requirements, and program benefits and provider contracts.</li>
<li>Process claims recoupments when needed.</li>
<li>Conform to established standards of performance for quality and timeliness.</li>
<li>Correctly match authorizations and PDRs to claims.</li>
<li>Coordinate benefits/other health coverage.</li>
<li>Use the QNXT claims processing module in an effective and efficient manner to process claims.</li>
<li>Use the JIVA system for PDR processing in an effective and efficient manner to process disputes.</li>
<li>Interpret medical group and provider contracts to determine claims payment methodologies.</li>
<li>Review and adjudicate claims (paper and EDI) and resolve claim edits and PDRs, using claims desk top procedures and operational reference materials.</li>
<li>Review claims for correct provider coding information and appropriateness of reported services and billing practices.</li>
<li>Review claims for necessity, limitations, and exclusions based on claims policies and procedures.</li>
<li>Review claims/PDRs for missing or incomplete information; request additional information needed to complete PDR and adjudication of claims.</li>
<li>Help with correct claims errors and reprocess claims.</li>
<li>Make informed decisions regarding the clearing of claim edits and payment of claims.</li>
<li>Document claims to support payments or decisions.</li>
<li>Process retro-terminations and Claims trouble shooter reports</li>
<li>Complete more complex claims processing tasks including claim adjustments, coordinating benefits with secondary carrier, claim reversals, etc.</li>
<li>Handle projects of smaller scale in claims from start to finish.</li>
<li>Perform user acceptance tests for projects.</li>
<li>Work with Claims management to resolve difficult or complex transactions and identify system and/or training-related opportunities to enhance Claims operations.</li>
<li>Respond to first level provider inquiries, call tracking tickets, misdirected claims, and faxes from providers.</li>
<li>Handle provider calls and call tracking tickets promptly and courteously regarding claims status, billing and payment issues, disputes, etc...</li>
<li>Provider Dispute Resolutions:
<ul>
<li>Respond to provider disputes.</li>
<li>Research provider disputes to ensure appropriate resolutions.</li>
<li>Maintain and update the Provider Dispute Log.</li>
<li>Help to update configuration in JIVA for Claims Department needs.</li>
<li>Complete claims processing adjustments to resolve issues.</li>
<li>Create letters according to the regulatory requirements and timelines.</li>
</ul>
</li>
<li>Maintain and update current desk procedures and reference materials.</li>
<li>Identify and report billing errors and collaborate with other departments to enhance processes.</li>
<li>Recognize system problems and work with ITS/BST to resolve.</li>
<li>Stay informed about the changes in regulations, program policies, and current processing procedures.</li>
<li>Be a Subject Matter Expert for claims and PDRs related meetings or workgroups.</li>
</ul>
WHAT YOU WILL BRING:
<ul>
<li>3 years prior work experience in claims operations environment in health care insurance business, preferably with focus on Medi-Cal claims</li>
<li>Knowledge of managed care and Medi-Cal reimbursement.</li>
<li>Hands-on working knowledge and background using claims processing system such as QNXT.</li>
<li>Demonstrated depth of experience in medical claims procedures, processes, governing rules, and all aspects of claims adjudication including solid knowledge of CPT/HCPCS, ICD-10 claims coding, and medical terminology.</li>
<li>Knowledge of Claims Editing Software preferred.</li>
<li>Knowledge of Medi-Cal benefits, claims processing, and claims regulatory requirements.</li>
<li>Basic knowledge of PDR and recoupment processing.</li>
<li>Process multiple types of claims and identify claim errors.</li>
<li>A high school diploma or equivalent; college degree preferred.</li>
</ul>
WHAT WE OFFER:
<ul>
<li>Health Benefits
<ul>
<li>Medical: You'll have a choice of medical plans, including options from Kaiser and Blue Shield of California, heavily subsidized by SFHP.</li>
<li>Dental: You'll have a choice of a basic dental plan or an enhanced dental plan which includes orthodontic coverage.</li>
<li>Vision: Employee vision care coverage is available through Vision Service Plan (VSP).</li>
</ul>
</li>
<li>Retirement – Employer-matched CalPERS Pension and 401(a) plans, 457 Plan.</li>
<li>Time off – 23 days of Paid Time Off (PTO) and 13 paid holidays.</li>
<li>Professional development: Opportunities for tuition reimbursement, professional license/membership.</li>
</ul>
ABOUT SFHP:
Established in 1997, San Francisco Health Plan (SFHP) is an award-winning, managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco County. SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 175,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services.
San Francisco Health Plan is proud to be an equal opportunity employer. We are committed to a work environment that supports, inspires, and respects all individuals and in which our people processes are applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military service status, citizenship, or other protected characteristics.
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.
San Francisco Health Plan is an E-Verify participating employer.
Hiring priority will be given to candidates residing in the San Francisco Bay Area and California.
#LI-Hybrid
(Hybrid remote/in-office)

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