Role Description This is a remote position based in California, and candidates must reside within the state. As a Senior Claims Examiner, you’ll play a vital role in helping businesses and individuals navigate complex Workers' Compensation claims. This is your opportunity to make a meaningful impact by resolving claims efficiently, mitigating risks, and delivering exceptional service. In this role, you’ll manage Workers' Compensation indemnity claims, ensuring they’re handled with care and precision. You’ll oversee complex claim issues, leveraging your expertise in litigation management and lien resolution to achieve fair outcomes. Your day-to-day will involve: - Maintaining accurate claim diaries - Updating reserves - Ensuring timely reporting to key stakeholders - Collaborating with legal teams - Identifying opportunities for subrogation - Working closely with clients to maintain satisfaction Additionally, you’ll: - Prepare and attend file reviews to ensure claims are progressing effectively - Negotiate settlements and resolve outstanding liens - Monitor and guide defense attorneys to achieve optimal outcomes - Ensure compliance with all regulatory requirements and deadlines Qualifications - High school diploma and 5 years related claims experience required - Appropriately licensed and/or certified in all states in which claims are being handled or able to obtain the licenses/certification per local requirements - Extensive knowledge of accepted industry standards and practices - Computer experience with related claims and business software - Bachelor's degree preferred Requirements - Ability to think critically and solve problems - Plan and organize activities - Serve clients and negotiate - Effectively communicate verbally and in writing - Embrace new challenges - Analytical skill necessary to make decisions and resolve complex issues inherent in handling losses - Ability to successfully negotiate the settlement and disposition of serious claims - Ability to interpret related documentation

Role Description Bring your claims expertise to a remote team committed to service excellence and operational success. - Work Style: Remote - Location Requirement: Gainesville, FL - FTE: Full-Time (1.0 FTE) This position is responsible for coordinating incoming and outgoing payer correspondence, reviewing claim documentation, supporting Epic account updates, and ensuring accurate claim processing and routing. Ideal candidates are detail-oriented, analytical, and thrive in a fast-paced environment while helping drive efficiency and accuracy across the revenue cycle team. Qualifications - High School Diploma/Equivalent Requirements - 2+ years of experience in insurance claims processing and support. - Working knowledge of insurance policies, coverage, and claims adjudication processes. - Experience investigating, analyzing, and resolving claim-related issues. - Strong communication and customer service skills with the ability to interact effectively with claimants and stakeholders. - Demonstrated ability to maintain accurate records and ensure compliance with regulatory and audit requirements.

• Day-to-day processing of claims for accounts: • Responsible for processing of claims (medical, dental, vision, and mental health claims) • Claims processing and adjudication. • Claims research where applicable. • Reviews and processes insurance to verify medical necessities and coverage under policy guidelines (clinical edit logic). • Incumbents are expected to meet and/or exceed qualitative and quantitative production standards. • Investigation and overpayment administration: • Facilitate claims investigation, negotiate settlements, interpret medical records, respond to Department of Insurance complaints, and authorize payment to claimants and providers. • Overpayment reviews and recovery of claims overpayment; corrected financial histories of patients and service providers to ensure accurate records. • Utilize systems to track complaints and resolutions. • Other responsibilities include resolving claims appeals, researching benefits, verifying correct plan loading.

Role Description This position is responsible for the coding and total processing of claims and triaging claim adjustments generated by our providers and subscribers or requested via Customer Service, for all lines of business. Processes claims utilizing established policies and procedures to review and correct error and warning messages. Research claims and ensures proper adjudication. - Codes and enters imaged claims and triages adjustments, submitted by members, providers and vendors. - Reviews and corrects on-line edit errors by interpreting generated warning messages. - Uses appropriate systems to research and accurately process claims. - Researches appropriate reference documents and imaged claims to make coding and payment decisions. - Reviews and processes claims that are in a pended status in accordance with processing procedures, policies and current contract specifications regarding coverage, contract limitations, and exceptions. - May identify and report possible system or Image problems to CPR or Supervisor so that corrective action may be taken. - All other duties and assignments as directed. Qualifications - Ability to communicate effectively and professionally with personnel, in both written and verbal form. - Must possess a strong attention to detail and an interest in preventing errors. - Ability to operate a personal computer (PC) and other office equipment (e.g., copy machine, fax machine, printer, calculator, etc.) as well as possess excellent keyboarding skills. - Demonstrate ability to be dependable and professional. - Demonstrate intrinsic initiative and time management skills. - Must possess a strong commitment to teamwork and an ability to foster an inclusive culture of diversity by working well and collaborating with others as needed. - Ability to accept feedback, learn, and adapt from guidance to be successful. - Ability to adapt to constant changing priorities and keeping daily responsibilities on task. - Ability to manage workload and ensure all tasks are completed within established timeframes. - Must be willing and able to work possible mandatory overtime as needed based on business needs. - Must be able to meet quality, productivity, and behavior expectations. - Must possess basic reading and arithmetic skills (reading and math comprehension). Requirements - Preferred familiarity with provider billing documents (including in/out of state hospitals, doctors, pharmacy, and suppliers) in order to code and enter appropriate data from each bill. - Preferred familiarity with medical terminology in order to correctly code and enter the appropriate ICD-10CM diagnosis code, procedure code, ancillary code, type of service, and qualifier code. - Preferred knowledge of both manual and automated aspects of claims processing and Image systems. - Preferred knowledge of claims payment policies and benefits. - Preferred competency in the use of computer applications, databases, and end user computing tools and programs, including proficiency in various software like Microsoft Windows, Email, Internet browsers, Instant Messenger, and Office (Word, Excel, etc.). Experience - Preferred FACETS claims Coding. - Preferred Facets claims processing. - Preferred WorkDesk Imaging. - Preferred Facets Customer Service Application. Education and Certifications - Must have a high school diploma or GED. Benefits - Comprehensive benefits package including Medical, Dental & Vision coverage. - Retirement Plan. - Generous time off including Paid Time Off, Holidays, and Volunteer time off. - Incentive Plan. - Tuition Reimbursement.