• Investigate, evaluate, and adjust PIP claims in accordance with Texas laws and company guidelines • Obtain information necessary to properly investigate and evaluate each case by corresponding with brokers, insureds, claimants, witnesses and others • Analyze medical records, billing, and documentation to determine coverage, liability, and damages • Ensure compliance with Texas Department of Insurance regulations and statutory deadlines • Handle complex and litigated PIP claims, including disputes and arbitration • Communicate effectively with claimants, attorneys, medical providers, and internal stakeholders • Review and negotiate medical bills and treatment plans for reasonableness and necessity • Identify potential fraud indicators and escalate as appropriate • Maintain accurate and timely claim file documentation • Provide guidance and mentorship to junior adjusters as needed • Manage claim inventory to meet productivity and quality standards

• The Claims Resolution Specialist plays a critical role in the healthcare revenue cycle by ensuring the accurate and timely submission and resolution of insurance and patient claims. • This position is responsible for claim billing, follow-up, and resolution for government, commercial, and patient payers. • The specialist investigates denied or unpaid claims, performs root cause analysis, documents findings, executes appropriate write-offs or corrections, and ensures compliance with payer guidelines and internal policies. • Submit and track insurance and patient claims for government (e.g., Medicare/Medicaid) and commercial payers. • Perform timely and thorough follow-up on unpaid or denied claims to ensure proper reimbursement. • Conduct root cause analysis on recurring denials or payment issues; escalate trends to management as needed. • Research payer policies and claim-specific requirements to ensure accurate claim resolution. • Process write-offs and adjustments according to established protocols and payer contracts. • Maintain clear, accurate, and thorough documentation of all claim-related activities and communications. • Collaborate with clinical, billing, and coding staff to resolve claim issues and ensure accurate claim submission. • Monitor aging reports and prioritize follow-up efforts based on payer deadlines and financial impact. • Prepare reports and summaries of problem accounts, denial patterns, and process inefficiencies for leadership review. • Assist in implementing process improvements to reduce denials and enhance revenue cycle performance. • Ensure compliance with HIPAA, payer guidelines, and internal billing policies. • Performs other duties as assigned.

• Be the designated claims representative for matters in coverage litigation and for claims where a separate coverage file is needed across multiple lines of insurance coverage offered by BHDIC • Draft detailed coverage position letters in those matters • At the direction of the Legal Department, serve as a point of contact and claim handler for Declaratory Judgment Actions • Document coverage claim files with litigation updates and accompanying legal filings and positional correspondence • Act as a fact witness for matters in coverage litigation • Address Florida Civil Remedy Notices and monitor the associated files • Assist with maintaining internal resources relevant to proper handling of coverage claims • Communicate and work directly with BHDIC’s Legal Department on a regular basis

• Utilize analytical skills to create a comprehensive estimate of damages for 1st and 3rd party material damage claims leading to the proper disposition • Build relationships with customers across multiple lines • Negotiate settlements and complete documentation of activities on complex files