Claims Director

Job Description: • Highly skilled and experienced at adjudication of accident and health medical claims and pharmacy benefits for traditional medical, employer stop loss specific and aggregate excess, HMO Re or Provider Excess of Loss, and Medical Excess of Loss and Reinsurance claims. • Audit and review of managed care and provider excess provider agreements, risk sharing documents and healthplan/TPA contracts. • Utilize in-house Claims Adjudication System (CAS), build Profiles and run data submissions for import & export of files. • Audit and review of employer stop loss specific and aggregate excess claims utilizing Summary Plan Descriptions, policies and related supporting documents. • Knowledgeable of CMS regulations, Medicare fee schedules, Medicare programs, Medicaid fee schedules & Medicaid programs for state level agencies. • Knowledge of internal claim systems and external claims systems utilized to perform claims review. • Ensuring assigned accounts have sufficient backup claim support; assume manager’s responsibilities during any absence. • Leading and structuring communications with clients, intermediaries and colleagues on a regular basis for assigned accounts. • Conduct peer editing and training. • Maintain Quality Review performance files. • Initiate regular communication with manager in respect of training needs for self or peers. • Occasional travel to perform claim support during off-site audits, projects, and assignments with the A&H audit team. Requirements: • 10+ years of medical claims or stop loss industry experience • Ability to work independently and collaborate on assignments in a fast-paced environment • Knowledge of first dollar medical and pharmacy claims, claim processing platforms, CMS regulations and medical terminology and coding • Well versed in self-insured and managed care concepts • Intermediate level MS Word and MS Excel • Must have US work rights • Must reside in the U.S. Benefits: • Medical PPO or HMO Plan (BCBS) • Dental Plan (MetLife) • Vision Plan (EyeMed) • Life Insurance Plan • Short Term Disability Plan • Long Term Disability Plan • 401k Employer Matching • Paid Time Off • Paid Holidays Apply tot his job