Title: Claims Specialist PACE Location: Work From Home, Indiana Work Type: Remote, Full Time Job Description: The PACE Claims Specialist I, is responsible for performing day-to-day claims processing and adjudication tasks while providing support to vendors and internal teams. This role plays an integral part in ensuring PACE medical claims are processed efficiently and in compliance with PACE policies and CMS requirements. The PACE program's vision is to provide individualized and joyful care through exemplary teamwork serving as many seniors as possible with the best quality-of-life in their communities. WHO WE ARE With 12 ministries and access points across Indiana and Illinois, Franciscan Health is one of the largest Catholic health care systems in the Midwest. Franciscan Health takes pride in hiring coworkers that provide compassionate, comprehensive care for our patients and the communities we serve. The PACE program's vision statement is to provide unmatched, individualized, and joyful care through teamwork that is worthy of praise so that seniors experience the best quality-of-life in their communities. PACE offers seniors and their families the care, nutrition, rehabilitation, transportation, and supportive services they need to remain healthy so that they can live in their own home. Franciscan is known for our mission of caring. WHAT YOU CAN EXPECT - Practice Hours: Monday - Friday, 8:00 a.m. - 5:00 p.m. Eastern - No Weekends, Evenings, or Holidays - Serves as point of contact for vendors and participants for concerns related to claims or billing. Performs customer service activities including, but not limited to, support and education to vendors during onboarding phase of partnership, communicating claim statuses to vendors, investigating vendor inquiries, and gathering information related to vendor claim appeals. - Performs duties related to the timely and accurate adjudication of PACE participant medical claims. This includes data entry, processing manual and electronic claims, verifying proper authorizations, and processing claim denials. Ensures claims adhere to CMS rules, Medicare guidelines, and PACE-specific policies. Collaborates with the interdisciplinary team (IDT) to resolve discrepancies in authorizations or documentation. Conducts any necessary follow up with internal and external stakeholders. - Assists with maintaining the vendor and provider network within the claims adjudication software. Builds and modifies vendor profiles as program's vendor network changes. Ensures accuracy of vendor profiles in relation to reimbursement structure in vendor contracts, provider lists, W-9s, etc. Enters paper claims into claim adjudication software upon receipt. - Supports Claim Specialist II in monthly EDPS reporting and error clearance. This includes, but is not limited to, reporting to regulatory agencies, clearing errors for resubmission of codes, and monthly auditing of EDPS return/output data. Prepares routine claim reports for review by leadership. - Collaborates with PACE intake and eligibility team members to maintain accurate participant eligibility record in claim adjudication software, driving accurate and compliant claim payments. - Assists with tracking vendor 1099s and gathering claims data for reinsurance reporting. Performs administrative tasks related to claims processing such as mailing vendor checks and remittance advice, mailing vendor notification letters, etc. - Works closely with internal stakeholders, including finance, compliance, and clinical teams, to facilitate claims processing workflows. Partners with external stakeholders, such as CMS or third-party vendors, to ensure seamless claims operations. QUALIFICATIONS - Associate's Degree- Finance, Business or Healthcare Administration- Preferred - Certified Medical Reimbursement Specialist- American Medical Billion Association- Preferred - 1 Year- Medical Claim Processing or Medical Claim Support Role Experience- Required TRAVEL IS REQUIRED: Never or Rarely JOB RANGE: PACE Claims Specialist I $20.25 - $26.33 INCENTIVE: Not Applicable EQUAL OPPORTUNITY EMPLOYER It is the policy of Franciscan Alliance to provide equal employment to its employees and qualified applicants for employment as otherwise required by an applicable local, state or Federal law. Franciscan Alliance reserves a Right of Conscience objection in the event local, state or Federal ordinances that violate its values and the free exercise of its religious rights. Franciscan Alliance is committed to equal employment opportunity. Franciscan provides eligible employees with comprehensive benefit offerings. Find an overview on the benefit section of our career site, jobs.franciscanhealth.org.

Role Description This position is located in the Department of Labor (DOL), Office of Workers' Compensation Programs (OWCP), Division of Energy Employees Occupational Illness Compensation Program (DEEOICP). The purpose of this position is to serve as a Unit supervisor assigned to an Adjudicatory and/or District Office with responsibility for leading, managing, and directing a staff of subordinate employees. This position is Outside the bargaining unit. The primary duties and responsibilities as the Supervisory Workers Compensation Claims Examiner include but are not limited to: - Plan, lead, and direct claims adjudication activities and performance of a Unit. - Accountable to Agency management for all aspects of the process for that Unit. - Manage the timeliness, quantity, and quality of work and service performed within the Unit. - Supervise and monitor the work of claims examiners responsible for researching, examining, and studying evidence in claim files. - Provide seasoned policy guidance, assistance, and direction to subordinate staff. - Continuously monitor workload reports to ensure the Unit's performance meets their division and OWCP operational performance goals. - Manage pending caseloads to ensure cases are processed timely. - Review all categories of cases that subordinates process as a performance and quality control mechanism. - Ensure the integrity of entries in automated systems such as status codes, name entries, address entries, medical condition codes, etc. - Adapt or develop procedures and techniques suited to changing operating conditions and workloads. Qualifications - IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE WILL NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. - POSITION TITLES ALONE CANNOT BE USED TO DETERMINE IF YOU ARE QUALIFIED. PLEASE LIST DATES IN MM/DD/YYYY FORMAT. - For GS-13: Applicants must have 52 weeks of specialized experience equivalent to at least the next lower grade level, GS-12 in the Federal Service. Requirements - Specialized experience that equipped the applicant with the particular knowledge, skills, and abilities (KSA's) to perform the duties of the position successfully. - Qualifying specialized experience for Supervisory Workers Compensation Claims Examiner includes: - Experience reading, interpreting, and applying government regulations. - Experience processing complex medical or compensation claims. - Experience reviewing and analyzing performance reports; determining priorities; and meeting organizational goals. - Experience dealing with both internal and external government customers. - Experience developing, mentoring, or leading staff.

Title: Disability and Leave Management Claims Specialist (Disability Claims Experience Required) (REMOTE) Location: UNITED STATES-Remote Job Description: What You Will Bring - Bachelor’s degree or equivalent work experience - 1+ years disability claims experience - Exceptional customer service skills - Maintains positive and effective interaction with challenging customers - Strong knowledge of disability and leave laws and regulations - Ability to handle sensitive information with confidentiality and professionalism Preferred Qualifications - Group Disability Claims experience - Exceptional written and oral communication skills demonstrated in previous work experience - Excellent organizational and time management skills with ability to multitask and prioritize deadlines - Ability to manage multiple and changing priorities - Detail oriented; able to analyze and research contract information - Demonstrated ability to operate with a sense of urgency - Experience in effectively meeting/ exceeding individual professional expectations and team goals - Demonstrated analytical and math skills - Ability to exercise critical thinking skills, risk management skills and sound judgment - Ability to adapt, problem solve quickly and communicate effective solutions - High level of flexibility to adapt to the changing needs of the organization - Self-motivated, independent with proven ability to work effectively on a team and work with others in a highly collaborative team environment - Continuous improvement mindset - A commitment to support a work environment that fosters diversity and inclusion - Proficiency in computer literacy and skills with the ability to work within multiple systems; proficiency with PC based programs such as Excel and Word Skills Analytical Thinking: Knowledge of techniques and tools that promote effective analysis; ability to determine the root cause of organizational problems and create alternative solutions that resolve these problems. Customer Support Operations: Knowledge of customer support techniques, tools, technologies, and best practices; ability to utilize all aspects of customer support operations to manage a call center. Customer Support Systems: Knowledge of principles and techniques used in customer support and ability to use applications, hardware, software, networking, and the applications environment used for customer support. Managing Multiple Priorities: Knowledge of effective self-management practices; ability to manage multiple concurrent objectives, projects, groups, or activities, making effective judgments as to prioritizing and time allocation. Problem Solving: Knowledge of approaches, tools, techniques for recognizing, anticipating, and resolving organizational, operational or process problems; ability to apply knowledge of problem solving appropriately to diverse situations. #LI-Remote About the Role At Equitable, we help clients secure their financial well-being so they can pursue long and fulfilling lives- a mission we’ve honed since 1859. Equitable is looking for an experienced Claims Specialist supporting Disability and Leave Management claims to join our team! The Claims Specialist is responsible for providing excellent customer service. You will be expected to utilize judgment and assess risk as you work with various business partners to render claim decisions and partner with internal and external resources. Reliability and dependability throughout our extensive training program is required. What You’ll Be Doing - Deliver an exceptional customer experience and ensure that customer commitments and deliverables are achieved - Communication via telephone, email, and text with employees, employers, attorneys, and others - Review and interpret medical records, utilizing resources as appropriate - Complete financial calculations - Gain an understanding and working knowledge of the Equitable claim and other applicable systems, policies, procedures, and contracts as well as regulatory and statutory requirements for claim adjudication - Apply contract/policy provisions to ensure accurate eligibility and liability decisions - Demonstrate and apply analytical and critical thinking skills - Verify on-going liability and develop strategies for return-to-work opportunities as appropriate - Document objective, clear and technical rationale for all claim determinations and demonstrate the ability to effectively communicate claim decisions to our customers via oral and written communication - Leverage a broad spectrum of resources, materials, and tools to render claims decisions - Provide timely and exceptional customer experience by paying appropriate claims accurately and timely, responding to all inquiries and maintaining expected service and quality standards - Work within a fast-paced environment, with tight deadlines, and demonstrate the ability to balance multiple priorities - Work independently as well as within a team structure This position offers a remote work schedule that allows you to stay fully engaged with your team to provide outstanding, customer‑focused service during our core hours (8\:30 AM–5\:30 PM EST). Periodic office visits may be requested based on business needs. The base salary range for this position is $50,000-$60,000. Actual base salaries vary based on skills, experience, and geographical location. In addition to base pay, Equitable provides compensation to reward performance with base salary increases, spot bonuses, and short-term incentive compensation opportunities. Eligibility for these programs depends on level and functional area of responsibility. For eligible employees, Equitable provides a full range of benefits. This includes medical, dental, vision, a 401(k) plan, and paid time off. For detailed descriptions of these benefits, please reference the link below. Equitable Pay and Benefits:Equitable Total Rewards Program

Title: Claims Examiner - Xcelys Remote, Temporary Location: Ontario, CA, United States Job Description: Req ID: 366967 NTT DATA strives to hire exceptional, innovative and passionate individuals who want to grow with us. If you want to be part of an inclusive, adaptable, and forward-thinking organization, apply now. We are currently seeking a Claims Examiner - Xcelys Remote, Temporary to join our team in Ontario, California (US-CA), United States (US). Senior Claims Auditor (Xcelys System) To serve as a Medical Claims Processor within the Xcelys environment. Provide subject-matter expertise on claims workflows and be a key contributor to system enhancements, audits, and process optimizations. Role Responsibilities: - Adjudication & Review - Process comprehensive medical claims using Xcelys and associated subsystems - Resolve complex pends, coding issues, and contract exceptions - Author overpayment/underpayment determinations and coordinate appeals - Quality & Compliance - Engage in quality reviews, audits, root cause analyses - Monitor accuracy, variance, and rework metrics - Ensure alignment with regulatory and internal compliance guidelines - Support - Act as escalation point and subject matter expert - Process & System Improvement - Participate in system testing, UAT, and workflow enhancements - Recommend improvements, document system and process changes - Reporting & Analytics - Prepare production, pending, and quality reports - Identify trends and recommend corrective actions - Cross-Functional Collaboration - Liaise with provider relations, legal, IT, compliance teams - Support internal initiatives related to claims systems / operational improvements Required Skills/Experience - 3+ years claims adjudication experience - Minimum of 1 year experience in Xcelys - 2+ years in coding (CPT, ICD-10, HCPCS) - 2+ years provider contracts, pricing, regulatory guidelines experience Preferences - Excellent analytical and communication skills - Experience training staff or acting as a mentor - Familiarity with system testing and documentation - Ability to manage high-volume workload and meet performance metrics Education: Verifiable high school diploma or GED About NTT DATA NTT DATA is a $30 billion business and technology services leader, serving 75% of the Fortune Global 100. We are committed to accelerating client success and positively impacting society through responsible innovation. We are one of the world's leading AI and digital infrastructure providers, with unmatched capabilities in enterprise-scale AI, cloud, security, connectivity, data centers and application services. our consulting and Industry solutions help organizations and society move confidently and sustainably into the digital future. As a Global Top Employer, we have experts in more than 50 countries. We also offer clients access to a robust ecosystem of innovation centers as well as established and start-up partners. NTT DATA is a part of NTT Group, which invests over $3 billion each year in R&D. Whenever possible, we hire locally to NTT DATA offices or client sites. This ensures we can provide timely and effective support tailored to each client's needs. While many positions offer remote or hybrid work options, these arrangements are subject to change based on client requirements. For employees near an NTT DATA office or client site, in-office attendance may be required for meetings or events, depending on business needs. At NTT DATA, we are committed to staying flexible and meeting the evolving needs of both our clients and employees. This contact information is for accommodation requests only and cannot be used to inquire about the status of applications. NTT DATA is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.