Property Claims Adjuster Req #681 United States **This is a Desk Adjuster position and can work remote, hybrid or in office** Summary: Under general supervision and following standard procedures with independent judgment, investigates, evaluates and resolves/disposes of general property claims to determine the extent of company liability; may include determination and evaluation of coverage, compensability, and liability in accordance with policy provisions by performing the following duties. Essential Duties and Responsibilities: - Follows corporate policies, procedures, and fair claims handling practices - Investigates claims to determine validity and extent of liability, including: - Obtains information necessary to properly investigate and evaluate each case by corresponding with agents, insureds, claimants, witnesses and others - Reviews and evaluates documentation, including applications, reports, and statements - Monitors appropriate claim outcomes through self-audit process - Delivers superior customer service to policyholders and agents, ensuring appropriate and timely resolution of claims service issues - Ensures legal, regulatory and fair claims handling compliance - Sets or recommends reserves based on results of claim investigation. - Within defined authority, manages, evaluates and concludes claims. Prepares and maintains claim reports. - May provide extensive interaction with insureds, agents, claimants, attorneys, and other service providers, including: - Conducts in-depth interviews and/or scene inspections - Attends settlement conferences and/or trials - May serve as a member of project teams, contributing to the achievement of project objectives. - Performs other duties as assigned. Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. EXP WITH GUIDEWIRE CLAIMS CENTER IS PREFERRED Education/Experience: Level 4: Two to four years related experience and/or training; or associate's degree (A.A.) from two-year college/technical school; or equivalent combination of education and related experience/training. A minimum requirement for this position is the ability to work legally in the United States. No visa sponsorship/support is available for this position, including for any type of U.S. permanent residency (green card) process.

Role Description This is a remote position. Must reside in California, preferably in our service area. Under general supervision, the Claims Supervisor is responsible for providing oversight and coordinating the daily operations of claims production or claims adjustment and auditing functions in a manner that meets established turnaround, quality and production goals, and regulatory standards. Work is varied and minimally to moderately complex and requires a limited to moderate degree of discretion and independent judgment. - Supervises Claims Analysts Essential Functions - Plans and assigns work; monitors department workload to ensure mandated turnaround times are met; makes timely and effective adjustments. - Identifies, monitors and analyzes appropriate metrics, including production, inventory and submission/billing patterns; develops timely and effective corrective action plans based on findings. - Develops, implements and maintains department policies and procedures; makes recommendations for revisions; communicates changes to appropriate individuals in a timely and effective manner. - Responds to and resolves or facilitates resolution of complex claims, appeals, provider disputes, and third-party liability cases. - Assists with the development and implementation of department-related upgrades and enhancements of transaction system and other tools. - Identifies, monitors and analyzes transaction system processing issues; corrects or escalates as required. - Works closely with interdepartmental units to improve workflow and processes: identifies issues and opportunities; initiates meetings; resolves issues or makes recommendations as required. - Prepares for and participates in regulatory audits: compiles audit packets, provides information, develops and monitors timely and effective corrective action plans. - Executes and monitors business plans; assists in the development and monitoring of department budget. - Identifies training needs and opportunities; develops and delivers routine and ad hoc department training. - Promotes and maintains an environment that supports HPSJ’s strategy, vision, mission and values. - Hires, supervises and retains a competent staff. Qualifications - In-depth knowledge of procedure coding and medical terminology, and their application in benefits; general medical policy benefits and exclusions; industry standard payment practices. - In-depth knowledge of claims processing systems, including coding. - Basic knowledge of claims administration metrics models. - Basic knowledge of audit processes, and the ability to effectively implement and maintain them. - Ability to read, interpret and apply complex written guidelines, instructions and other materials. - Ability to develop, execute and monitor relevant business plans. - Basic analytical skills. - Strong oral and written communication skills with the ability to communicate with diverse individuals inside and outside of HPSJ. - Good presentation skills. - Strong facilitation, problem solving and conflict resolution skills. - Strong interpersonal skills with the ability to maintain effective working relationships with diverse individuals inside and outside of HPSJ. - Ability to commit to and facilitate an atmosphere of collaboration and teamwork. - Strong customer service skills. - Demonstrated ability to articulate and support HPSJ’s vision, mission, values and strategy, integrate into management practices, and foster their manifestation among staff. - Demonstrated ability to supervise staff in a manner that maximizes employee performance and business results. - Ability to develop and deliver relevant and effective training and supporting materials. - Intermediate skills in Word and Excel, including the ability to develop formulas and links. - Basic mathematics skills. - Ability to handle confidential information with appropriate discretion. Requirements - HS diploma. - At least one year experience as a claim's supervisor in healthcare; or - At least two years’ experience as a claims lead in healthcare; or - At least four years progressively responsible experience in healthcare claims. Benefits - Robust and affordable medical coverage including HMO and PPO plan options. - Employee Wellness Program promoting physical, mental, and financial well-being. - Dental and vision plan with multiple provider choices. - Generous paid time off (accrue up to 3 weeks of PTO, 4 paid floating holidays, and 9 paid holidays). - CalPERS retirement pension program, automatic employer-paid retirements contributions, plus a voluntary defined contribution plan. - Two flexible spending accounts (FSAs) for healthcare and dependent care expenses. - Employer-Paid Term Life and AD&D Insurance. - Employer-Paid Disability Insurance. - Employer-Paid Assistance Program (EAP). - Health Advocacy to help you navigate medical care and benefits. - Voluntary supplemental benefits including medical, legal, identity theft protection. - Online discount mall. - Tuition reimbursement. - Remote work contingent on business needs and company guidelines. - A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do. Physical Demands - Work may require frequent sitting, standing, and walking, constant repetitive motion, frequent talking and listening, closeup and distance vision requirements. - Some work may require occasional travel based on the responsibilities of the position and business needs and occasional handling materials up to 50 pounds. Emotional/Psychological Demands - Ability to cope with a fast-paced work environment, working under pressure, dynamic priorities and deadlines, constant decision making, working irregular hours, emotional and sensitive situations. Work Environment - Work may be performed in a remote, hybrid, or onsite setting depending on the requirements of the position and business needs. - For roles performed remotely, employees are expected to maintain a secure, distraction-free workspace, and reliable internet connectivity consistent with company standards. Important Notice The duties, qualifications, and physical and emotional requirements listed in this job description are not exhaustive. Health Plan of San Joaquin reserves the right to revise this job description at any time.

• Review veterinary medical records, clinical notes, invoices, and policy information to evaluate claim eligibility and determine claim outcomes • Apply policy language, claims guidelines, and established processes consistently and accurately • Conduct secondary claim reviews as part of the appeals process and communicate claim rationale clearly and professionally • Investigate complex claim scenarios by gathering, validating, and interpreting relevant medical and policy information • Identify missing or incomplete information and proactively obtain required documentation from veterinary clinics, specialists, or pet owners • Communicate with veterinary professionals, pet owners, and internal teams via phone and email regarding claim decisions, status updates, and policy questions • Deliver an efficient, empathetic, and positive experience for pet owners and veterinary partners during potentially sensitive situations • Maintain accurate records and documentation within multiple internal systems • Collaborate with cross-functional teams to support operational excellence and continuous improvement initiatives • Contribute ideas and feedback that enhance claims processes, workflows, and customer experience

Role Description Trillium Health Resources has a career opening for a Senior Claims Specialist to join our team! The Senior Claims Specialist performs data analysis, auditing and finalizes adjudication results for claims designated for pre-payment review and post payment review of claim adjudication results through research and knowledge of billing guidelines and policies established by CMS, and NC Medicaid as well as Trillium policies and procedures. This position is also responsible for assisting providers by phone or email with claims processing questions as well as communicating with internal and external stakeholders to facilitate efficient claims resolution. On a typical day, you might: - Analyze and audit claims adjudication results to determine if claims were accurately submitted and processed according to NC Medicaid guidelines. - Analyze and audit claim attachments/medical documentation necessary to appropriately adjudicate a claim. - Analyze, audit and take appropriate actions for claims delayed for adjudication due to rejection errors. - Identify adjudication errors, provider billing errors, and the need for technical assistance. - Ensure the claims system and manual processes are incorporating required actions by reviewing and applying information from departmental trainings, published coverage policies and other NCDHHS documents. - Provide training, education and technical assistance to provider agencies based on analysis or audit findings related to basic claim submission guidelines, denial management, system use and updates. - Recognize and report suspected system issues or concerns to immediate supervisor for follow-up based on data analysis. Qualifications - High School Diploma/GED and two (2) years of experience in the claims processing or billing or medical coding field; OR equivalent combination of education/experience. - Must have a valid driver’s license. - Must reside within North Carolina. - Must be able to travel within catchment as required. - Associate’s degree in Healthcare Administration, Business, or a Human Services field (such as Psychology, Social Work, etc.) preferred. - Hospital claims experience and knowledge preferred. - Experience in the areas of physical health claims processing or medical coding preferred. - Experience working with Managed Care billing software preferred. - Certified Professional Coder (CPC), Certified Professional Biller (CPB), Certified Medical Reimbursement Specialist (CMRS) or similar certification preferred. Benefits - Typical working hours: 8:30 am – 5:00 pm; flexible work schedules with some roles with management approval. - Work-from-home options available for most positions. - Health Insurance with no premium for employee coverage. - Flexible Spending Accounts. - 24 days of Paid Time Off (PTO) plus 12 paid holidays in your first year. - NC Local Government Retirement Pension (defined-benefit plan). - 401k with 5% employer match and immediate vesting. - Public Service Loan Forgiveness (PSLF) qualifying employer. - Quarterly stipend for remote work supplies. Company Description Trillium Health Resources is a Tailored Plan and Managed Care Organization (MCO) serving 46 counties across North Carolina. We manage services for individuals with serious mental health needs, substance use disorders, traumatic brain injuries, and intellectual/development (IDD) disabilities. Our mission is to help individuals and families build strong foundations for healthy, fulfilling lives.