Claims Examiner Job at NTT DATA (Plano)

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

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

Medical Claims Examiner

We are looking for a detail-focused Medical Claims Examiner to join an insurance...

Location

United States , Greenville

Salary:

Not provided

Robert Half

Expiration Date

Until further notice

Requirements

At least 1 year of direct medical claims processing and adjudication experience with responsibility for final payment decisions.
Practical knowledge of applying plan benefits, including deductibles, coinsurance, copays, and benefits coordination.
Working familiarity with ICD-10 diagnosis coding, CPT/HCPCS procedure coding, revenue codes, bill types, and explanation of benefits review.
Experience using provider networks, contract terms, or fee schedules to price and evaluate claims accurately.
Background in a third-party administrator, self-funded, or medical insurance claims environment is strongly preferred.
Ability to distinguish true claims adjudication work from customer service, enrollment, billing-only, intake, or audit-only functions.
Strong written and verbal communication skills, along with proficiency in Microsoft Word, Excel, and Outlook.
Proven ability to manage a high-volume workload while maintaining accuracy and adapting to changing priorities.

Job Responsibility

Review and adjudicate medical, dental, vision, and flexible spending account claims from intake through final payment determination.
Examine suspended or flagged claims to identify billing discrepancies, duplicate submissions, unbundled charges, or other questionable claim activity.
Resolve system-related claim exceptions by making manual corrections before claims are finalized for payment.
Apply member benefits, provider contract terms, fee schedules, and applicable regulations to calculate accurate reimbursement outcomes.
Interpret coding and billing details, including diagnosis and procedure information, to support proper claim handling.
Escalate complex claim issues or unclear situations to leadership when additional review or guidance is needed.
Manage assigned exception reports and follow through on outstanding claim items in a timely manner.
Meet established productivity, turnaround, and quality expectations while maintaining dependable attendance at the Greenville, South Carolina worksite.

What we offer

medical, vision, dental, and life and disability insurance
401(k) plan

Bilingual Claims Examiner

Position: Claims Examiner – Full-time, contract up to 12 months, with possibilit...

Location

Canada , Winnipeg

Salary:

Not provided

Randstad

Expiration Date

July 28, 2026

Requirements

Minimum of one year of experience in a customer service environment
Excellent oral and written communication skills in both French and English (considered a strong asset)
Ability to understand complex instructions and basic contractual language
Basic knowledge of medical terminology
Excellent typing and data entry skills
proficiency in Microsoft Office programs
Demonstrated excellence in telephone etiquette and customer service
Strong organizational and time management skills, with the ability to manage multiple priorities effectively
Experience working in the disability insurance field is considered an asset

Job Responsibility

Review the system, claim documents, and contracts to confirm if eligibility requirements are met
Responsible for follow-up calls to plan sponsors and plan members within 24 hours of receiving initial claim information
Communicate via telephone or email with plan sponsors or members to verify any inconsistencies or missing/inaccurate information
Draft denial letters intended for plan sponsors and affected members
Assess and manage claims with a predetermined limited duration (known as "Quick Pay" claims)
Escalate files: If a claim does not meet "Quick Pay" eligibility criteria, transfer the file to the Disability Case Manager (DCM) for assessment and management, and to DCAs (Disability Claims Assistants) for benefit calculations
File and organize documents accordingly

What we offer

Career advancement opportunities
Potential for a permanent position

Fulltime

Claims Examiner - Xcelys

The Senior Claims Examiner role at NTT DATA involves adjudicating medical claims...

Location

United States , Ontario

Salary:

Not provided

NTT DATA

Expiration Date

Until further notice

Requirements

5+ years claims adjudication experience
2 years’ experience in Xcelys or equivalent claims adjudication systems
2 years’ experience (CPT, ICD-10, HCPCS)
1 year experience with system testing and documentation
Deep knowledge of provider contracts, pricing, regulatory guidelines
Excellent analytical and communication skills
Experience training staff or acting as a mentor
Ability to manage high-volume workload and meet performance metrics

Job Responsibility

Process comprehensive medical claims using Xcelys and associated subsystems
Resolve complex pends, coding issues, and contract exceptions
Author overpayment/underpayment determinations and coordinate appeals
Engage in quality reviews, audits, root cause analyses
Monitor accuracy, variance, and rework metrics
Ensure alignment with regulatory and internal compliance guidelines
Act as escalation point and subject matter expert
Participate in system testing, UAT, and workflow enhancements
Recommend improvements, document system and process changes
Prepare production, pending, and quality reports

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