Claims Specialist Fully Remote • Allied Benefit Systems - CHICAGO, IL 60606 Overview Salary Range $48,000.00 - $50,000.00 Salary Position Type Full Time Category Claims Description 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 - 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 with exceeding all established goals - Prior experience in Adjustment Processing is preferred but not required COMPETENCIES - Accountability - Analytical Thinking - Collaboration - Communication - Customer Focus - Functional Expertise - Initiative 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.

Role Description To analyze complex or technically difficult workers' compensation claims to determine benefits due; to work with high exposure claims involving litigation and rehabilitation; to ensure ongoing adjudication of claims within service expectations, industry best practices and specific client service requirements; and to identify subrogation of claims and negotiate settlements. Essential Functions and Responsibilities - Analyzes and processes complex or technically difficult workers' compensation claims by investigating and gathering information to determine the exposure on the claim; manages claims through well-developed action plans to an appropriate and timely resolution. - Negotiates settlement of claims within designated authority. - Calculates and assigns timely and appropriate reserves to claims; manages reserve adequacy throughout the life of the claim. - Calculates and pays benefits due; approves and makes timely claim payments and adjustments; and settles claims within designated authority level. - Prepares necessary state fillings within statutory limits. - Manages the litigation process; ensures timely and cost effective claims resolution. - Coordinates vendor referrals for additional investigation and/or litigation management. - Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims for our clients. - Manages claim recoveries, including but not limited to: subrogation, Second Injury Fund excess recoveries and Social Security and Medicare offsets. - Reports claims to the excess carrier; responds to requests of directions in a professional and timely manner. - Communicates claim activity and processing with the claimant and the client; maintains professional client relationships. - Ensures claim files are properly documented and claims coding is correct. - Refers cases as appropriate to supervisor and management. Additional Functions and Responsibilities - Performs other duties as assigned. - Supports the organization's quality program(s). - Travels as required. Qualifications - Education & Licensing: Bachelor's degree from an accredited college or university preferred. Professional certification as applicable to line of business preferred. - Experience: Five (5) years of claims management experience or equivalent combination of education and experience required. - Skills & Knowledge: - Subject matter expert of appropriate insurance principles and laws for line-of-business handled, recoveries offsets and deductions, claim and disability duration, cost containment principles including medical management practices and Social Security and Medicare application procedures as applicable to line-of-business. - Excellent oral and written communication, including presentation skills. - PC literate, including Microsoft Office products. - Analytical and interpretive skills. - Strong organizational skills. - Good interpersonal skills. - Excellent negotiation skills. - Ability to work in a team environment. - Ability to meet or exceed Service Expectations. Work Environment - Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines. - Physical: Computer keyboarding, travel as required. - Auditory/Visual: Hearing, vision and talking. Requirements - Credit security clearance, confirmed via a background credit check, is required for this position. Benefits - A comprehensive benefits package is offered including but not limited to: - Medical, dental, vision. - 401k and matching. - PTO. - Disability and life insurance. - Employee assistance. - Flexible spending or health savings account. - Other additional voluntary benefits.

Role Description Are you looking for an opportunity to join a global industry leader where you can bring your big ideas to help solve problems for some of the world’s best brands? Apply your knowledge and experience to adjudicate complex customer claims in the context of an energetic culture. - Deliver innovative customer-facing solutions to clients who represent virtually every industry and comprise some of the world’s most respected organizations. - Be a part of a rapidly growing, industry-leading global company known for its excellence and customer service. - Leverage Sedgwick’s broad, global network of experts to both learn from and to share your insights. - Take advantage of a variety of professional development opportunities that help you perform your best work and grow your career. - Enjoy flexibility and autonomy in your daily work, your location, and your career path. - Access diverse and comprehensive benefits to take care of your mental, physical, financial, and professional needs. Qualifications - Bachelor's degree from an accredited college or university preferred. - Professional certification as applicable to line of business preferred. - Four (4) years of claims management experience or equivalent combination of education and experience required. Requirements - To analyze mid- and higher-level workers compensation claims to determine benefits due. - To ensure ongoing adjudication of claims within company standards and industry best practices. - To identify subrogation of claims and negotiate settlements. Benefits - Flexible work schedule. - Referral incentive program. - Opportunity to work in an agile environment. - Career development and promotional growth opportunities. - A diverse and comprehensive benefits offering including medical, dental vision, 401K on day one. Work Environment - Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines. - Physical: Computer keyboarding, travel as required. - Auditory/Visual: Hearing, vision and talking.

• Using a PC /Microsoft Window environment, adjudicates claims with the aid of the Facets and Macess Systems. • Reviews and ensures the accuracy of all provider, member and claim line information for all claims for which the examiner is responsible. • Reviews and ensures the accuracy of all changes to claim line information based on information received from other departments and in accord with available benefit information. • Is responsible for the timely and accurate adjudication of claims that are suspended to other MVP departments for benefit and/or authorization determination. • Meets or exceeds department quality and work management standards for claims adjudication. • Successfully completes a course of comprehensive formal training in all areas of benefits determination, system navigation, and MVP policy. • Suspends, investigates and resolves claim issues by coordinating with appropriate departments, based on criteria set by those departments. • Handles inquiries regarding suspended claims from other departments and identifies trends in suspensions based on these inquiries and other feedback. • Keeps abreast of all benefit changes. • Contribute to our humble pursuit of excellence by performing various responsibilities that may arise, reflecting our collective goal of enhancing healthcare delivery and being the difference for the customer.