Role Description The Claims Investigator conducts insurance claims investigations on behalf of both employers/clients and injured workers. This unique opportunity breaks new ground in the workers’ compensation and injury liability fields through an innovative advocacy-based claims investigation paradigm that also raises the investigator’s interpersonal skills to new levels. In addition to performing the day-to-day insurance claims investigations with claimants, their supervisors, and witnesses, DigiStream’s enhanced Claims Investigator position also includes the opportunity to work in a more personally impactful context. Generally, the position also requires initiative in scheduling, preparing, and conducting a wide range of claims investigations and communicating with the General Manager regarding results obtained and updating clients as needed. The written reports obtained from these in-person interviews identify essential psychosocial factors in addition to the legally-relevant objective details—for purposes of seeing positive outcomes for employers and injured workers alike. Responsibilities - Conduct in-person recorded interviews with injured workers, their supervisors, witnesses, and management regarding industrial incidents and injuries - Conduct accident scene investigations including scene photographs, measurements, and analysis of equipment to determine cause of injury or third-party liability - Obtain and secure evidence, such as audio recordings, medical releases, photographs, police reports, court records, and other evidence - Regularly update the client, DigiStream supervisor, and the case tracking system regarding the progress of investigations - Complete well-written and in-depth reports on case findings within 48 hours of statement - Troubleshoot "locate" issues and utilize office staff to locate hard-to-reach claimants - Track and maintain hourly billing for accurate time reporting - Work under deadlines and multitask - Remain available and prepared to testify in court or provide testimony in depositions - Other duties as may be assigned from time to time Qualifications - Bachelors' Degree required (Criminal Justice, English, Psychology, History, Political Science or other writing intensive major preferred) - Ability to interact with subjects of an investigation in a professional manner while developing rapport and connection, and extracting necessary information - Familiarity and comfort with navigating ambiguity as well as a basic understanding of the workers' compensation system or desire to learn the system - Ability to read, analyze, and distill information from documents and forms and apply it to an investigation - Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form - Ability to maintain confidentiality of information

Title: ACO Medicaid Claims Review Specialist Location: Remote,United States Full time Job Description: Site: Mass General Brigham Health Plan Holding Company, Inc. Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. Job Summary 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 Education - High School Diploma or Equivalent required - Associate's Degree preferred Licenses and Credentials - Professional Coder (CPC) license preferred - Pharmacy Technician certification and/or a degree in a pharmacy-related field preferred Experience - 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, Skills, and Abilities - 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. - Strong attention to detail and accuracy in claim submissions and recordkeeping. - 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. Additional Job Details (if applicable) Working Conditions - 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 Remote Type Remote Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America) Pay Range $17.71 - $25.28/Hourly Grade 2 At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

Role Description With minimal oversight, the Senior Claims Adjuster I is responsible for the timely and accurate management of workers' compensation claims in California. This includes handling medical and indemnity benefits, addressing litigation and complex issues, and managing moderate to high exposure cases. Must work West Coast hours (M-F 8am-5pm PST) and have experience adjusting CALIFORNIA work comp claims. - Completes initial contacts to obtain necessary information, verify coverage, determine compensability and develop a plan of action. Completes and maintains claim data integrity. - Independently analyzes case facts to establish timely and accurate reserves using knowledge and experience with medical disabilities and related costs, as well as judgment of extent of disability. - Collaborates with Corporate Claims to proactively evaluate and mitigate high exposure losses. - Provides timely and appropriate customer service within established best practices. Maintains ongoing professional communications with all internal and external customers. - Accurately evaluates and pays benefits in compliance with statutory and company procedures and guidelines. Files appropriate state forms, as needed. - Proactively manages or coordinates medical treatment to continue to move the claim forward. Uses internal and external resources to contain costs and manage exposure. - Reviews and analyzes litigation and legal issues. Directs legal strategy and participates in preparation of the case for litigation. Collaborates with defense attorney to move claims to resolution. - Completes detailed settlement analysis and recommends appropriate settlement value, utilizing in-depth knowledge of appropriate workers’ compensation insurance principles and laws, subrogation recoveries, offsets and deductions, claim and disability duration, cost containment principles; including medical management practices and Social Security and Medicare application procedure as applicable. - Regularly reviews caseload and proactively takes action to guide claims efficiently and effectively to closure. Uses a high degree of independent judgment to render accurate decisions. - Mentors other team members and acts as a Subject Matter Expert for legal, jurisdiction and Company needs. - Other duties as assigned. Qualifications - 7 or more years of related claims experience including complex claim handling. Internal candidates with proven results may also qualify. - Superior communication and customer service skills and proficiency in an imaged environment. - Demonstrated knowledge of workers’ compensation laws and ability to adhere to statutes, regulations and company policies and practices, as well as related claim management procedures/protocols. - Self-motivated with the ability to work independently with minimal direction. The ability to multi-task and prioritize, adhere to deadlines and complete assignments accordingly. - Excellent analytical, problem solving and decision-making skills. - Equivalent combinations of education and experience may be considered. Requirements - Certification: WCCP, AIC, ARM, CPCU or other insurance designation preferred. - Education: Bachelor’s degree or equivalent business experience preferred. Benefits - Salary Range: $60,000-105,000 and a comprehensive benefits package. Company Description As a dynamic, fast-growing provider of workers' compensation insurance and services, we are seeking a goal-oriented individual willing to put their ideas to work! We offer a positive, challenging work environment, combined with an opportunity to build your career as you help us grow our business, in innovative and imaginative ways that are uniquely EMPLOYERS! - Headquartered in Nevada, EMPLOYERS attributes its long-standing success to its most valuable resource, our employees across the United States. - EMPLOYERS is known for the quality service and expertise we provide to our clients, and the exemplary work environment we provide for our employees. - We live and breathe our core values: Integrity, Customer Focus, Collaboration, Initiative, Accountability, Innovation, and Personal Fulfillment. - At EMPLOYERS, you’ll discover an energetic environment that inspires top achievement.

Role Description Our insurance carrier client is currently seeking a skilled and experienced Personal Auto Insurance Claims Adjuster to join their Claims Department. This will be a Remote position. As a Personal Auto Insurance Claims Adjuster, you will be responsible for investigating, evaluating, and settling personal auto insurance claims. You will work closely with policyholders, third-party claimants, and internal teams to assess liability, determine coverage, and negotiate settlements in accordance with company policies and regulatory requirements. Key Responsibilities: - Conduct thorough investigations to determine coverage, liability, and damages related to personal auto insurance claims. - Gather and analyze relevant information, including accident reports, witness statements, and vehicle inspections. - Evaluate vehicle damage and injuries to determine the extent of damages and the appropriate settlement amount. - Collaborate with repair shops, medical professionals, and other experts to assess damages accurately. - Interpret insurance policies to determine coverage and liability. - Communicate coverage decisions clearly and effectively to policyholders and claimants. Qualifications - Bachelor's degree in a related field or equivalent work experience. - 5+ years of experience as a Personal Auto Insurance Claims Adjuster. - Strong knowledge of auto insurance policies, coverage, and regulations. - Excellent communication and negotiation skills. - Detail-oriented with strong analytical and problem-solving abilities. Benefits - Compensation: $60,000 - $85,000/year - Comprehensive health, dental, and vision insurance. - Annual bonus between 5% - 10% based on company and personal performance. - 20 days of PTO. - 100% Company paid medical benefits to employee AND family. - 401k company matches 100% up to the first 3%. Company Description