• Conduct both virtual and on-site investigations by visiting policyholders’ residences to assess property damage, determine liability, evaluate the extent of loss, and negotiate fair settlements. • Use claims handling software, a company car, and a laptop to determine claims-related damage and write estimates in a paperless environment. • Evaluate and report on potential subrogation opportunities. • Report incidents involving theft, fraud, or arson to appropriate state and industry agencies. • Perform duties independently, with work directly impacting management outcomes. • Act as a company representative in public interactions, maintaining a professional demeanor consistent with management standards. • Engage regularly with a variety of stakeholders, including policyholders, claimants, agents, witnesses, contractors, law enforcement, fraud and arson investigators, attorneys, medical professionals, and other relevant parties. • Use strong customer service skills to negotiate with policyholders to settle the claim. • Perform additional duties as assigned. • Promote safety at all times and comply with safety/ergonomic standards as outlined in relevant company published manuals. • Employees assigned to the Catastrophe team will be required to travel away from their residence for a specified period of time, usually consisting of 2-3 days. Although this is not a CAT-specific role, hires will be expected to commit to 1–3 CAT deployments per year.

Role Description As a BlueCard/ITS Claims Specialist, this role ensures accurate, compliant adjudication across complex BlueCard claims, translates BlueWeb and Association changes into operational action, partners closely with Regence and InterPlan stakeholders, and monitors and improves IPP (InterPlan Program) performance. The Claims Specialist/BlueCard Hybrid serves as an enterprise escalation point, leads cross-functional initiatives, and drives training, quality, and process improvements that safeguard claim outcomes and member experience. What YOU will do: - BlueWeb Review: - Monitor BlueWeb for Association updates and analyze release notes to determine claim, pricing, and training impacts. - Track provider terminations and communicate impacts; coordinate continuity-of-care and disruption analysis. - Serve as SME on BlueCard/ITS claims processing rules and operational program requirements. Coach team members accordingly on guidelines and changes. - Collaboration with Regence: - Coordinate Association projects and rule interpretation with Regence and InterPlan Executives. - Act as key escalation point for Plan-to-Plan issues. - Cascade InterPlan communications to internal teams. - Operational Change Leadership: - Oversee complex ITS/BlueCard workflows; lead system and pricing enhancement projects. - Test and validate system updates; refine ITS/BlueCard policies and procedures. - Conduct root-cause analysis on recurring issues and implement improvements. - IPP Score Monitoring: - Monitor and communicate InterPlan performance metrics (IPP). - Track quality and productivity metrics; lead improvement initiatives. - Claims Adjudication: - Oversee daily ITS claims workflows and ensure timely, accurate adjudication across all claim types. - Serve as the primary escalation point for the most complex, sensitive, or high-impact ITS/BlueCard claim issues. - Partner with leadership to refine ITS policies, update procedures, and support operational strategy. - Act as a liaison with BCBS host/home plans and external partners for escalated claim issues. Qualifications - High school diploma required, Associate’s Degree preferred. - 5-7+ years of claims processing experience within the insurance industry. - 3-5 years of BCBS claims processing experience. - 1+ years of proven leadership experience. - Expert Excel skills with the ability to manipulate data independently. - Expert-level understanding of ITS/BlueCard processing, pricing methodologies, and BCBS national programs. - Strong leadership, communication, and coaching abilities. - Ability to manage competing priorities and support team performance. - High-level analytical skills with the ability to interpret data and drive improvements. Compensation The base salary range for this position in the greater Seattle area is $47.89/hr - $55.76/hr for a level IV and varies dependent on geography, skills, experience, education, and other job or market-related factors. While we are looking for level I, we may consider level II for highly qualified candidates. Benefits - Seventeen (IC) days paid time off (individual contributors). - Eleven paid holidays. - Two paid personal and one paid volunteer day. - Company-subsidized medical, dental, vision, and prescription insurance. - Company-paid disability, life, and AD&D insurances. - Voluntary insurances. - HSA and FSA pre-tax programs. - 401(k)-retirement plan with company match. - Annual $500 wellness incentive and a $600 wellness reimbursement. - Remote work and continuing education reimbursements. - Discount program. - Parental leave. - Up to $1,000 annual charitable giving match. How we Support your Work, Life, and Wellness Goals At HMA, we believe in recognizing and celebrating the achievements of our dedicated staff. We offer flexibility to work schedules that support people in all time zones across the US, ensuring a healthy work-life balance. Employees have the option to work remotely or enjoy the amenities of our renovated office located just outside Seattle with free parking, gym, and a multitude of refreshments. Our performance management program is designed to elevate career growth opportunities, fostering a collaborative work culture where every team member can thrive. We also prioritize having fun together by hosting in-person events throughout the year including an annual all hands, summer picnic, trivia night, and a holiday party. Company Description HMA is the premier third-party health plan administrator across the PNW and beyond. We relentlessly deliver on our promise to provide medium to large-size employers with customized health plans. We offer various high-quality, affordable healthcare plan options supported with best-in-class customer service.

Role Description Primary responsibility for managing, investigating, and resolving professional and general liability claims for the Stanford Medicine enterprise. Requires coordination with internal stakeholders and staff, as well as oversight and management of panel counsel. Analyzes complex medical claims and evaluates exposure and liability. Assists in handling other types of exposures as warranted, including cyber/privacy, construction, and property claims. What you will do - Develops action plan for managing litigated claims, evaluates insurance coverage, attends mediation and trial, monitors litigation costs, handles discovery, and provides recommendations for ultimate resolution. - Oversees legal defense strategy, retains outside counsel, coordinates support for investigation, reviews attorney invoices, and monitors counsel’s compliance with litigation management guidelines. - Investigates pre-suit claims, reviews medical records, interviews providers, retains consultants when necessary, communicates with patients and/or families, and directly negotiates settlements when warranted. - Prepares claims reports and settlement evaluations. Presents high-exposure cases to leadership and stakeholders, including reinsurance partners. - Maintains accurate defense and indemnity reserves. - Manages claims files in internal database. Inputs all work product to ensure case information is accurate and entered in a timely manner. - Investigates cyber and privacy claims. Pursues recovery in construction and property claims. Manages associated insurance reporting and communication requirements. - Assists in other matters as assigned. Handles Medical Board and NPDB reporting. Prepares and conducts Risk Management educational presentations. Qualifications - Juris Doctor (JD) required. California license preferred. - Five (5) years of progressively responsible and directly-related claim management experience. Requirements - Strong writing, communication, and presentation skills. - Effective negotiation skills. - Ability to analyze complex legal problems and develop solutions. - Ability to review and evaluate medical records and literature. - Knowledge of laws pertaining to professional and general liability litigation. - Ability to work effectively both as a team player and leader. Benefits - Base Pay Scale: Generally starting at $100.03 - $132.51 per hour. - The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. - This pay scale is not a promise of a particular wage. Company Description Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.

Role Description Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at the forefront of transformation with one of the world’s leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage. Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills. We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more. Job Description Summary - Review claims to ensure accurate coding, appropriate documentation, and compliance with applicable billing regulations and payer guidelines. - Adjudicate claims to pay, deny, or pend as appropriate in a timely and accurate manner according to company policy and desktop procedure. - Review and research assigned claims by navigating multiple systems and platforms, then accurately capturing the data/information necessary for processing (e.g., verify pricing/fee schedules, contracts, prior authorization, applicable member benefits). - Communicate and collaborate with external departments to resolve claims errors/issues, using clear and concise language to ensure understanding. - Review and adjudicate medical claims submitted by healthcare providers, insurance companies, and patients to identify discrepancies, errors, or potential fraud. - Analyze and validate the assigned diagnosis codes (ICD-10) and procedure codes (CPT) on medical claims to ensure accurate representation of services rendered and compliance with coding standards. - Keep up to date with Desktop Procedures and effectively apply this knowledge in the processing of claims and in providing customer service. - Identify and escalate system issues, configuration issues, pricing issues etc. in a timely manner. - Ensure that the medical claims include complete and accurate documentation supporting the services rendered, including physician notes, test results, and other relevant records. - Meet the performance goals established for the position in areas of productivity, accuracy, and attendance that drives member and provider satisfaction. Qualifications - High School Diploma or Equivalent required - Associate's Degree preferred - Professional Coder (CPC) license preferred - Pharmacy Technician certification and/or a degree in a pharmacy-related field preferred - At least 1-2 years of healthcare billing experience required - At least 2–4 years of experience in healthcare claims processing, billing, or the health insurance industry (e.g., hospital or physician billing) highly preferred - Experience in pharmacy claims processing or adjudication, with a strong working knowledge of pharmacy terminology and National Drug Code (NDC) standards. - Experience with core healthcare claims processing and billing system highly preferred - Strong working knowledge of managed care concepts and medical coding, including ICD-10, CPT, HCPCS, and Revenue Codes highly preferred - Knowledge of Medicaid/ACO claims processing - Knowledge of claim types including professional, facility, DME, outpatient, and inpatient - Ability to prioritize and manage aged claims (e.g., 30+ day inventory) to meet program guidelines and turnaround requirements - Strong attention to detail and accuracy in claim review, submissions, and documentation - Familiarity with insurance plans, government programs, and their billing requirements. - Excellent communication skills, both written and verbal, to interact effectively with insurance companies, patients, and colleagues. - Strong customer service orientation and ability to handle sensitive or difficult situations with empathy and professionalism. Requirements - This is a full-time role with a Monday through Friday, 8:30-5 schedule - This is a remote role that can be done from most US states - Scheduled Weekly Hours: 40 - Employee Type: Regular - Work Shift: Day (United States of America) - Pay Range: $17.71 - $25.28/Hourly - Grade: 2 Benefits - Competitive base pay - Comprehensive benefits - Career advancement opportunities - Differentials, premiums, and bonuses as applicable - Recognition programs designed to celebrate your contributions and support your professional growth EEO Statement Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.