• Oversees the management and analysis of reinsurance claims, including complex and high value exposures. • Ensures accurate reporting, billing, and recovery of reinsurance assets while acting as a subject matter expert on treaty agreements. • Partners with claims teams to support effective handling, optimize recoveries, and maintain compliance with contractual requirements. • Evaluate underlying claims to determine reinsurance applicability and coverage alignment with precision. • Interpret reinsurance treaties to drive accurate reporting and ensure full contractual adherence. • Collaborate cross functionally with underwriters, brokers, and actuaries to assess claim developments and optimize outcomes. • Enforce strict compliance with internal protocols while upholding operational integrity and consistency.

At Luminare Health , our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers. Join HCSC and be part of a purpose-driven company that will invest in your professional development. Job Summary This position includes a variety of claim administrative and technical tasks that support a Claim Unit and/or vendor staff, as well as the Claims Team and serves as a liaison for any internal departments. In addition to these tasks, the Senior Claims Analyst is responsible for all of the same tasks as a Claim Analyst including the accurate adjudication and processing of medical, dental, vision, or other related claims, including related correspondence and/or electronic inquiries for assigned groups. All claims and inquiries are handled according to the established plan documents, claim processing guidelines, and established total turnaround times. Also advise team members regarding claim processing procedures. Life & Disability - Sr Claims Analyst Secure and analyze claim information to make life and disability benefit determinations in accordance with policy provisions and appropriate state and federal laws; achieving results by effective use of all appropriate resources. Calculate benefit payments and communicate claim decisions on new and continuing claims. Provide responsive and caring customer service. All tasks completed under general supervision of management.Required Job Qualifications: - High School diploma or GED equivalent - 3 years prior medical claim processing experience - Ability to work in a fast-paced, customer centric & production driven environment - Excellent verbal and written communication skills - Ability to work effectively with employees/members, providers, clients and differing levels of co-workers including Client Managers and all levels of staff - Demonstrated critical thinking, to carry out instructions furnished in oral, written or diagram form - Flexible; open to continued process improvements - Self-directed individual who works well with minimal supervision - Good leadership, organizational and interpersonal skills - Ability to effectively handle with complex situations and reach resolution - Ability to analyze and interpret documents and Summary Plan Descriptions (SPDs) - Ability to adapt to various system platforms, and to effectively use MS Excel/Word Preferred Job Qualifications: - Health Insurance/Third Party Administrator Experience **This is a Telecommute (Remote) role. Candidates must live within the following states: IL, IN, IA, KS, MO, MT, NM, NC, OK, PA, TN, TX or WI** Sponsorship is not available #LI-NR1 #LI-Remote Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process! EEO Statement: We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics. Pay Transparency Statement: At Luminare, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for associates. The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan. Min to Max Range: $17.71 - $33.25 Exact compensation may vary based on skills, experience, and location.

Claims Examiner II--------------------------------------------------------------- The Claims Examiner II is an intermediate level position responsible for the timely review, investigation and adjudication of all types of Medicaid, Medicare, group and individual medical, dental, and mental health claims. Estimated Hiring Range: $22.82 - $27.89 Bonus Target: Bonus - SIP Target, 5% Annual Current CareOregon Employees: Please use the internal Workday site to submit an application for this job. --------------------------------------------------------------- Essential Responsibilities - Adjudicate medical, dental and mental health claims in accordance and compliance with plan provisions, state and federal regulations, and CareOregon policies and procedures. - Re-adjudicate, adjust or correct claims, including some complex and difficult claims as needed. - Consistently meet or exceed the quality and production standards established by the department and CareOregon. - Provide excellent customer service to internal and external customers. - Collaborate and share information with Claims teams and other CareOregon departments to achieve excellent customer service and support organizational goals. - Determine eligibility, benefit levels and coordination of benefits with other carriers; recognize and escalate complex issues to the Lead or Supervisor as needed. - Investigate third party issues as directed. - May review, process and post refunds and claim adjustments or re-adjudications as needed. - Report any overpayments, underpayments or other possible irregularities to the Lead or Supervisor as appropriate. - Generate letters and other documents as needed. - Proactively identify ways to improve quality and productivity. - Continuously learn and stay up to date with changing processes, procedures and policies. Experience and/or Education Required - Minimum 2 years’ experience as a Medical Claims Examiner or other role that requires knowledge of medical coding and terminology (e.g., medical billing, prior authorizations, appeals and grievances, health insurance customer service, etc.) Preferred - Experience using QNXT, Facets, Epic systems Knowledge, Skills and Abilities Required Knowledge - Knowledge of CPT, HCPCS, Revenue, CDT and ICD-10 coding - Knowledge of medical, dental, mental health and health insurance terminology Skills and Abilities - Understanding of or ability to learn state and federal laws and other regulatory agency requirements that relate to medical, dental, mental health and health insurance industry and Medicaid/Medicare industry - Ability to perform fast and accurate data entry - Strong spoken and written communication skills - Basic computer skills (ability to use Microsoft Outlook, Word and Excel) and learn new systems as needed - Good customer service skills - Ability to participate fully and constructively in meetings - Strong analytical and sound problem-solving skills - Detail orientation - Strong organizational skills and time management skills - Ability to work in a fast-paced environment with multiple priorities - Ability to work effectively with diverse individuals and groups - Ability to learn, focus, understand, and evaluate information and determine appropriate actions - Ability to accept direction and feedback, as well as tolerate and manage stress - Ability to see, read, hear, speak, and perform repetitive finger and wrist movement for at least 6 hours/day - Ability to lift, carry, reach, and/or pinch small objects for at least 1-3 hours/day Working Conditions Work Environment(s): ☒ Indoor/Office ☐ Community ☐ Facilities/Security ☐ Outdoor Exposure Member/Patient Facing: ☒ No ☐ Telephonic ☐ In Person Hazards: May include, but not limited to, physical and ergonomic hazards. Equipment: General office equipment Travel: May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used. Work Location: Work from home Schedule: Monday - Friday, 8:00 AM to 5:00 PM We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package. Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. CareOregon offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks. Please contact your recruiter for more information. We are an equal opportunity employer CareOregon is an equal opportunity employer.  The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.

• Communicate with claimants, employers and various medical professionals through phone and e-mail to gather information regarding the Short-Term Disability claim. • Collaborate with fellow case managers, nursing case managers and consulting physicians to make appropriate and timely claim determinations. • Review complex medical records and effectively leveraging a variety of tools and resources to understand appropriate approval durations and future action planning. • Complete accurate financial calculations consistent with company and state guidelines. • Provide exceptional customer service and proactively recognize customer needs and areas of opportunity. • Identify and recommend process improvements and organizational initiatives to positively influence the team and quality.