Claims Examiner Job at Randstad (Winnipeg)

Claims Examiner

Our Client is one of Leading Health Plan in US providing services in Florida sta...

Location

United States , Plano

Salary:

Not provided

NTT DATA

Expiration Date

Until further notice

Requirements

University degree or equivalent that required formal studies of the English language and basic Math
6+ months of experience where you had to apply business rules to varying fact situations and make appropriate decisions
6+ months of data entry experience that required a focus on quality including attention to detail, accuracy, and accountability for your work product
6+ months of experience using a computer with Windows PC applications that required you to use a keyboard, navigate screens, and learn new software tools
6+ months of experience that required prioritizing your workload to meet deadlines

Job Responsibility

Review and process insurance claims
Validate Member, Provider and other Claim’s information
Determine accurate payment criteria for clearing pending claims based on defined Policy and Procedure
Coordination of Claim Benefits based on the Policy & Procedure
Maintain productivity goals, quality standards and aging timeframes
Scrutinizing Medical Claim Documents and settlements
Organizing and completing tasks per assigned priorities
Developing and maintaining a solid working knowledge of the healthcare insurance industry and of all products, services and processes performed by the team
Resolving complex situations following pre-established guidelines

Fulltime

Claims Examiner

NTT DATA is currently seeking a Claims Examiner - Xcelys Remote, Temporary to jo...

Location

United States , Ontario

Salary:

Not provided

NTT DATA

Expiration Date

Until further notice

Requirements

Reviews written dispute requests received from providers of denied or incorrect payments based on contractual arrangements with providers and non-contractual providers. Regarding either Professional or Institutional Claims.
Ability to interpret provider and health plan contracts to ensure accurate payment of claims or denial of services based on the terms of the provider contract and the financial responsibility as set in the health plan contract. Including RBRVS and Medicare guidelines as it applies to contracted and non-contracted providers.
Adjust claims, as appropriate, including calculation of interest and penalties due when applicable.
Ability to identify potential issues related to system configuration, benefits, eligibility, authorizations, etc. affecting the Claims Departments ability to process claims accurately and forwarding those issues to the correct internal department, attaching all necessary documentation, to ensure the system is updated, as appropriate and follow-up with these departments.
Plan and organize workload to ensure efficient and compliance resolution of issues.
Communicate to Provider in writing, for all disputes utilizing system formatted letters in a clear and concise manner in accordance with all guidelines set by the department
Responsible for requesting special check run requests to insure compliance
Warning reports are monitored daily to insure compliance
Provider education calls completed based on outcomes of PDR
Responsible for documenting each dispute in Provider Dispute Database accurately for reporting purposes for management reports to all customers internally and externally as required by AB1455.

Job Responsibility

Reviews written dispute requests received from providers of denied or incorrect payments based on contractual arrangements with providers and non-contractual providers. Regarding either Professional or Institutional Claims.
Ability to interpret provider and health plan contracts to ensure accurate payment of claims or denial of services based on the terms of the provider contract and the financial responsibility as set in the health plan contract. Including RBRVS and Medicare guidelines as it applies to contracted and non-contracted providers.
Adjust claims, as appropriate, including calculation of interest and penalties due when applicable.
Ability to identify potential issues related to system configuration, benefits, eligibility, authorizations, etc. affecting the Claims Departments ability to process claims accurately and forwarding those issues to the correct internal department, attaching all necessary documentation, to ensure the system is updated, as appropriate and follow-up with these departments.
Plan and organize workload to ensure efficient and compliance resolution of issues.
Communicate to Provider in writing, for all disputes utilizing system formatted letters in a clear and concise manner in accordance with all guidelines set by the department
Responsible for requesting special check run requests to insure compliance
Warning reports are monitored daily to insure compliance
Provider education calls completed based on outcomes of PDR
Responsible for documenting each dispute in Provider Dispute Database accurately for reporting purposes for management reports to all customers internally and externally as required by AB1455.

Claims Examiner

We are looking for a detail-oriented Claims Examiner to join our team in Greenvi...

Location

United States , Greenville

Salary:

Not provided

Robert Half

Expiration Date

Until further notice

Requirements

Proven experience in handling Property and Casualty claims, demonstrating expertise in claims processing
Solid knowledge of New York State insurance regulations and compliance requirements
Strong analytical and problem-solving skills to evaluate claims and make sound decisions
Excellent communication skills, both written and verbal, to interact effectively with stakeholders
Ability to negotiate settlements and resolve disputes while maintaining professionalism
Familiarity with reviewing and interpreting estimates, reports, and medical documentation
High level of organizational skills to manage multiple claims and ensure accurate record-keeping
Proficiency in identifying potential fraud or subrogation opportunities and taking action accordingly

Job Responsibility

Conduct detailed investigations and assessments of Property and Casualty claims, including analyzing coverage and policy terms
Oversee the claims process from initial notification through resolution, ensuring timely and accurate handling
Engage empathetically and effectively with policyholders, agents, attorneys, and vendors to address inquiries and concerns
Resolve disputes and conflicts with attention to detail while adhering to policy guidelines and regulations
Negotiate settlements within your authority, even in challenging or high-pressure scenarios
Review supporting documentation such as estimates, reports, and medical records to evaluate the validity of claims
Monitor compliance with New York State insurance regulations and company standards throughout the claims process
Maintain organized and accurate claim files, ensuring documentation is timely and thorough
Identify opportunities for fraud detection or subrogation and take appropriate action

What we offer

Medical, vision, dental, and life and disability insurance
Company 401(k) plan
Free online training

Fulltime

Claims Examiner

We are seeking a detail-oriented Claims Examiner to join a fast-paced, customer-...

Location

United States , New Haven

Salary:

Not provided

Robert Half

Expiration Date

Until further notice

Requirements

3+ years of Claims Examiner experience or related transferable experience
Knowledge of workers’ compensation regulations (preferred but not required)
Excellent analytical and problem-solving skills
Strong communication (verbal and written) abilities
Ability to manage multiple priorities and meet deadlines
High attention to detail and organizational skills
Proficiency in Microsoft Office
Ability to collaborate effectively with cross-functional teams
Commitment to delivering high-quality customer service

Job Responsibility

Manage workers’ compensation claims from setup through closure
Review claim and policy information to support investigations
Conduct thorough investigations, including gathering statements from claimants, insured parties, and medical providers
Determine claim compensability based on collected facts
Communicate claim decisions, including denials, to relevant stakeholders
Prepare detailed reports on investigations, settlements, and claim evaluations
Administer statutory medical and indemnity benefits in a timely manner
Set and adjust reserves within authority limits and recommend changes as needed
Monitor claim progress and recommend corrective actions to leadership
Coordinate with attorneys on hearings and litigation

What we offer

medical, vision, dental, and life and disability insurance
eligible to enroll in our company 401(k) plan

Fulltime

Claims Examiner

Berkshire Hathaway Specialty Insurance (BHSI) has an exciting opportunity for a ...

Location

United States , Atlanta, GA/Boston, MA/Chicago, IL/New York, NY

Salary:

100000.00 - 120000.00 USD / Year

Berkshire Hathaway Specialty Insurance

Expiration Date

Until further notice

Requirements

College degree required, JD preferred
1-5 years of professional liability claim handling experience or matching equivalency
Demonstrate technical competence in the handling of specialized claims
Ability to work independently and assimilate learning materials on many different subjects from various sources
Excellent interpersonal, communication, investigative and negotiation skills
Ability and willingness to work effectively in a team environment and handle multiple tasks simultaneously
Experience in handling and adjusting claims in multiple jurisdictions and must possess, or be willing to obtain, the required licenses

Job Responsibility

Manage and adjust Architects & Engineers Professional Liability claims impacting primary and excess policies while ensuring the highest level of customer service and technical claim file quality
Proactively handle claims from first notice of loss through ultimate resolution while advising internal partners and meeting with clients and brokers
Collaborate and partner with the insured and broker in the handling and adjudication of claims
Analyze and draft coverage letters as appropriate and communicate coverage positions effectively
Conduct, coordinate, and proactively handle the investigation process and ensure timely resolution of claims
Directly and closely monitor assignments to experts and defense counsel as necessary
Evaluate information related to coverage, liability, and damages to determine the extent of exposure to the insured and the company
Draft reports, set reserves within authority, or make claim recommendations concerning reserve changes
Travel to conferences, mediations, and trials as necessary

What we offer

Comprehensive Health, Dental and Vision benefits
Disability Insurance (both short-term and long-term)
Life Insurance (for you and your family)
Accidental Death & Dismemberment Insurance (for you and your family)
Flexible Spending Accounts
Health Reimbursement Account
Employee Assistance Program
Retirement Savings 401(k) Plan with Company Match
Generous Holiday and Paid Time Off
Tuition Reimbursement

Fulltime

New

Bilingual Claims Examiner - French and English

Are you passionate about helping people? Do you enjoy solving problems and findi...

Location

Canada , Winnipeg

Salary:

Not provided

Randstad

Expiration Date

August 15, 2026

Requirements

Minimum of one year within a customer service environment
Excellent oral and written communication skills in both French and English would be considered an asset
Must be able to understand complex instructions and basic contractual language
Knowledge of basic medical terminology
Strong typing and data entry skills
proficiency with Microsoft Office programs
Demonstrates excellence in phone etiquette and client service
Strong and effective organizational and time management skills with the ability to manage multiple priorities
Working experience within disability insurance is an asset.

Job Responsibility

Review system, claim documents and contract to confirm if eligibility requirements are met
Accountable for the outreach call to Plan Sponsors and Plan Members within 24 hours of receipt of initial claim information
Responsible to communicate via phone calls/emails to verify any discrepancies, missing or unclear information from either Plan Sponsor or Plan Member
Responsible for declination letter to Plan Sponsor and Plan Member accordingly
Adjudicate and manage the claim if expected to be for a limited duration (known as Quick Pay claims)
If claim does not meet eligibility for a Quick Pay claim, transfer the claim to the Disability Case Manager for claim adjudication and management and to DCAs for benefit calculation
File documents accordingly.

What we offer

Full time opportunity: 37.5 hours per week in office full time to start with option of hybrid depending on capability
8 month contract with potential to have a permanent position
Career advancement options
Being a part of a great team.

Fulltime

New

Bilingual Claims Examiner

Review system, claim documents and contract to confirm if eligibility requiremen...

Location

Canada , Winnipeg

Salary:

Not provided

Randstad

Expiration Date

August 15, 2026

Requirements

Minimum of one year within a customer service environment
Excellent oral and written communication skills in both French and English would be considered an asset
Must be able to understand complex instructions and basic contractual language
Knowledge of basic medical terminology
Strong typing and data entry skills
proficiency with Microsoft Office programs
Demonstrates excellence in phone etiquette and client service
Strong and effective organizational and time management skills with the ability to manage multiple priorities
Working experience within disability insurance is an asset

Job Responsibility

Review system, claim documents and contract to confirm if eligibility requirements are met
Accountable for the outreach call to Plan Sponsors and Plan Members within 24 hours of receipt of initial claim information
Responsible to communicate via phone calls/emails to verify any discrepancies, missing or unclear information from either Plan Sponsor or Plan Member
Responsible for declination letter to Plan Sponsor and Plan Member accordingly
Adjudicate and manage the claim if expected to be for a limited duration (known as Quick Pay claims)
If claim does not meet eligibility for a Quick Pay claim, transfer the claim to the Disability Case Manager for claim adjudication and management and to DCAs for benefit calculation
File documents accordingly

What we offer

Work Flexibility: A full-time position (37.5 hrs/week) based in Winnipeg—initially on-site to ensure you have the best support around you, transitioning to a hybrid model as you grow in the role
Long-Term Stability: An initial 11-month contract with strong potential to transition into a permanent role
A Launchpad for Your Career: Genuine advancement opportunities to propel your professional journey forward
A Unique Culture: Join a fantastic team where collaboration is at the heart of everything we do

Fulltime

Claims Examiner - Xcelys

Location

United States , Plano

Salary:

Not provided

NTT DATA

Expiration Date

Until further notice

Requirements

Reviews written dispute requests received from providers of denied or incorrect payments based on contractual arrangements with providers and non-contractual providers. Regarding either Professional or Institutional Claims
Ability to interpret provider and health plan contracts to ensure accurate payment of claims or denial of services based on the terms of the provider contract and the financial responsibility as set in the health plan contract. Including RBRVS and Medicare guidelines as it applies to contracted and non-contracted providers
Adjust claims, as appropriate, including calculation of interest and penalties due when applicable
Ability to identify potential issues related to system configuration, benefits, eligibility, authorizations, etc. affecting the Claims Departments ability to process claims accurately and forwarding those issues to the correct internal department, attaching all necessary documentation, to ensure the system is updated, as appropriate and follow-up with these departments
Plan and organize workload to ensure efficient and compliance resolution of issues
Communicate to Provider in writing, for all disputes utilizing system formatted letters in a clear and concise manner in accordance with all guidelines set by the department
Responsible for requesting special check run requests to insure compliance
Warning reports are monitored daily to insure compliance
Provider education calls completed based on outcomes of PDR
Responsible for documenting each dispute in Provider Dispute Database accurately for reporting purposes for management reports to all customers internally and externally as required by AB1455

Job Responsibility

Reviews written dispute requests received from providers of denied or incorrect payments based on contractual arrangements with providers and non-contractual providers. Regarding either Professional or Institutional Claims
Ability to interpret provider and health plan contracts to ensure accurate payment of claims or denial of services based on the terms of the provider contract and the financial responsibility as set in the health plan contract. Including RBRVS and Medicare guidelines as it applies to contracted and non-contracted providers
Adjust claims, as appropriate, including calculation of interest and penalties due when applicable
Ability to identify potential issues related to system configuration, benefits, eligibility, authorizations, etc. affecting the Claims Departments ability to process claims accurately and forwarding those issues to the correct internal department, attaching all necessary documentation, to ensure the system is updated, as appropriate and follow-up with these departments
Plan and organize workload to ensure efficient and compliance resolution of issues
Communicate to Provider in writing, for all disputes utilizing system formatted letters in a clear and concise manner in accordance with all guidelines set by the department
Responsible for requesting special check run requests to insure compliance
Warning reports are monitored daily to insure compliance
Provider education calls completed based on outcomes of PDR
Responsible for documenting each dispute in Provider Dispute Database accurately for reporting purposes for management reports to all customers internally and externally as required by AB1455

Select Country

Claims Examiner

Job Description

Job Responsibility

Requirements

Nice to have

What we offer

Looking for more opportunities?

Claims Examiner

Claims Examiner

Claims Examiner

Claims Examiner

Claims Examiner

Claims Examiner

Bilingual Claims Examiner - French and English

Bilingual Claims Examiner

Claims Examiner - Xcelys

Our AI answers in your language