• Manage and process incoming claims efficiently, ensuring accuracy, fairness, and timely resolution • Communicate directly with customers, providers, and partners to gather necessary documentation and clarify case details. • Assist in claims review: Working along with our Claims Manager to investigate claims by reviewing documentation, identifying any discrepancies or inconsistencies, and escalating when appropriate. • Maintain detailed and compliant records for audit and regulatory purposes • Collaborate cross-functionally with product, engineering, and underwriting teams to improve claims workflows and automate routine tasks • Collaborate with cross-functional teams to understand the external and internal customer needs and implement solutions that enhance productivity. • Provide feedback and insights to improve internal policies, tools, and customer communications • Monitoring statistical data to ensure efficient claims handling is maintained. • Help build and refine our claims playbook, SOPs, and knowledge base from the ground up

Job DetailsJob Location: Allied Benefit Systems - CHICAGO, IL 60606Position Type: Full TimeSalary Range: $48,000.00 - $50,000.00 SalaryJob Category: Claims POSITION SUMMARY The Claims Specialist reviews, analyzes, and make determinations regarding payment, partial payment, or denial of medical, vision, and dental claims, based upon specific knowledge and application of the client’s customized plan. Assist with specific tasks as needed and assigned by the Management Team and support of the Virtual Insurance Claim Team. ESSENTIAL FUNCTIONS Read, analyze, understand, and ensure compliance with clients’ customized plans. (A plan may be hundreds of pages or more). Learn, adhere to, and apply all applicable privacy and security laws, including but not limited to HIPAA, HITECH and any regulations promulgated thereto. Request, review and analyze any physician notes, hospital records or police reports. Interview claimants, physicians, hospitals and other third parties for additional information. Consult with other professionals such as attorneys, nurses, physicians and auditors who can offer additional evaluation of a claim. Independently review, analyze, and make determinations of claims for: 1) reasonableness of cost; 2) unnecessary treatment by physicians and hospitals; and 3) fraud. Process claims in the QicLink System. Review, analyze and add applicable notes to the QicLink System. Document all information gathered in available systems as needed, including the QicLink System and alliedbenefit.com. Review billed procedure and diagnosis codes on claims for billing irregularities. Review and analyze specific procedure and diagnosis codes for medical necessity. Determine whether claimant’s plan covers the claim submitted and how much money, if any, should be paid. Authorize payment, partial payment or denial of claim based upon individual investigation and analysis. (On a yearly basis, responsible for determining claims payments totaling millions of dollars on behalf of Allied’s clients). Review Workflow Manager daily to document and release pended claims. Review Pended Claim Reports and close out pended claims for which no response has been received. Review Suspended Claim Reports and follow up on open issues. Process Adjustment Claims when necessary, due to corrected claims as well as applying refunds in the QL system. Assist and support other claims adjusters as needed and when requested. Attend continuing education classes as required, including but not limited to HIPAA training. Other duties as assigned. EDUCATION High School Diploma required, and College Preferred. Continuing education in all areas affecting group health and welfare plans is required. EXPERIENCE AND SKILLS Applicants must have a minimum of five (5) years of medical claims analysis and adjudication experience (including dental and vision claims analysis). Applicants must have strong analytical skills and knowledge of computer systems and CPT and ICD-10 coding terminology. Applicants must demonstrate the desire to assist the Team with exceeding all established goals. Prior experience in Adjustment Processing is preferred but not required. POSITION COMPETENCIES Job Knowledge Time Management Accountability Communication Initiative Customer Focus PHYSICAL DEMANDS This is a standard desk role that requires extended periods of sitting and computer work WORK ENVIRONMENT Remote Here at Allied, we believe that great talent can thrive from anywhere. Our remote friendly culture offers flexibility and the comfort of working from home, while also ensuring you are set up for success. To support a smooth and efficient remote work experience, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 100Mbps download/25Mbps upload. Reliable internet service is essential for staying connected and productive. The company has reviewed this job description to ensure that essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills, and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate. Compensation is not limited to base salary. Allied values our Total Rewards, and offers a competitive Benefit Package including, but not limited to, Medical, Dental, Vision, Life and Disability Insurance, Generous Paid Time Off, Tuition Reimbursement, EAP, and a Technology Stipend. Allied reserves the right to amend, change, alter, and revise, pay ranges and benefits offerings at any time. All applicants acknowledge that by applying to the position you understand that the specific pay range is contingent upon meeting the qualification and requirements of the role, and for the successful completion of the interview selection and process. It is at the Company's discretion to determine what pay is provided to a candidate within the range associated with the role. Qualifications

Company : Highmark Inc.Job Description : JOB SUMMARY This job is responsible for screening, reviewing, evaluating online entry, correcting errors and/or performing quality control review and final adjudication of paper/electronic claims. Determines whether to return, deny or pay claims following organizational policies and procedures. Reviews processed claims and inquiries to determine corrective action and takes the corrective action steps using enrollment, benefit, and historical claim processing information. ESSENTIAL RESPONSIBILITIES: - Receives and processes claims to include entering/verifying claims data; determines if claim information is complete and correct. (40%) - Resolves claim edits, reviews history records and determines benefit eligibility for service. Reviews payment levels to arrive at final payment determination; elevates issues to next level of supervision, as appropriate. (35%) - Meets all production and quality standards, ensuring timeliness and accuracy of all work given by support staff/management. Maintains accurate records including timekeeping records. (15%) - Attends all required training classes. (10%) - Other duties as assigned or requested. ​ EDUCATION Required - High School Diploma/GED Substitutions - None Preferred - None EXPERIENCE Required - None Preferred - 1 year of related experience ​ LICENSES or CERTIFICATIONS Required - None Preferred - None SKILLS - Ability to take direction and to navigate through multiple systems simultaneously. - Knowledge of administrative and clerical procedures and systems such as word processing and managing files and records. - Ability to use mathematics to adjudicate claims. - Ability to solve problems within pre-defined methods and guidelines. - Knowledge of operating systems specific to claim processing. - Ability to thoroughly read guidelines ensuring claim accuracy and following directions. Language (Other than English): None Travel Requirement: 0% - 25% PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS Position Type Office-based Teaches / trains others regularly Never Travel regularly from the office to various work sites or from site-to-site Never Works primarily out-of-the office selling products/services (sales employees) Never Physical work site required Yes Lifting: up to 10 pounds Constantly Lifting: 10 to 25 pounds Occasionally Lifting: 25 to 50 pounds Never Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements. Pay Range Minimum: $18.00 Pay Range Maximum: $21.99 Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets. Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law. We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org California Consumer Privacy Act Employees, Contractors, and Applicants Notice

• Responsible for working with repair facilities to validate, adjudicate, and approve payment for diagnostics and repair recommendations • Properly adjudicates claims within approval limit and in accordance with department & industry standards • Accurately notates all actions taken and interactions with shops and customers within internal systems • Manages list of assigned pending claims and provides timely follow up with repair facilities