Claims Specialist

• Review, analyze, and process pharmacy claims with accuracy, timeliness, and adherence to company and regulatory standards.
• Identify discrepancies, investigate claim issues, and determine appropriate resolutions.
• Communicate effectively with pharmacies, providers, and internal teams to clarify information and resolve errors.
• Support audits and quality reviews by maintaining detailed, accurate claim documentation.
• Identify trends and share insights that can improve claim accuracy and efficiency.
• Uphold confidentiality and compliance with HIPAA and corporate policy standards.

Pharmacy Claims Representative

• Proactively manages assigned claims caseload comprised of complex damages that require commensurate knowledge and understanding of claims coverage including potential legal liability.
• Partners with vendors and internal business partners to facilitate complex claims resolution.
• May also involve external regulatory coordination to ensure appropriate documentation and compliance.
• Investigates claim damages by conducting research from various sources, including the insured, third parties, and external resources.
• May identify and resolve potential discrepancies and identifies subrogation potential resulting from unusual characteristics.
• Identifies coverage concerns, reviews prior loss history, determines and creates Special Investigation Unit (SIU) referrals, when appropriate.
• Determines coverage through analyzing information involving complex policy terms and contingencies.
• Determines and negotiates complex claims settlement within authority limits.
• Develops recommendations and collaborates with management for determining settlement amounts outside of authority limits and accurately manages claims outcomes.
• Maintains accurate, thorough, and current claim file documentation throughout the claims process.
• Advance knowledge of estimating technology platforms and virtual inspection tools.
• Utilizes platforms and tools to prepare claims estimates to manage complex property insurance claims.
• Supports workload surges and catastrophe (CAT) response operations as needed, including mandatory on-call dates and potential evening, weekend, and/or holiday work outside normal work hours.
• May be assigned CAT deployment travel with minimal notice during designated CATs.
• Works various types of claims, including ones of higher complexity, and may be assigned additional work outside normal duties as needed.
• Works independently solving complex problems with minimal guidance; acts as a resource for colleagues with less experience.
• Adjusts complex claims with attorney involvement.
• Recognizes and addresses jurisdictional challenges such as applicable legislation and construction considerations.
• May require travel to resolve claims, attend training, and conduct in-person inspections.
• Ensures risks associated with business activities are effectively identified, measured, monitored, and controlled in accordance with risk and compliance policies and procedures.

Property Claims Adjuster Specialist – Desk

• Adjusts attorney-involved moderately complex bodily injury claims with demonstrable injuries (e.g. torn meniscus, broken bones, disc herniations), as well as all auto physical damage associated with those claims
• Identifies, confirms, and makes coverage decisions on moderately complex bodily injury claims
• Investigates loss details, determines legal liability, evaluates, negotiates, and arrives at claim settlement within appropriate authority guidelines
• Clearly documents thought process, investigation, evaluation, negotiation, and settlement decisions
• Prioritizes and manages assigned claims workload to keep members and other involved parties informed, provides timely claims status updates
• Collaborates and supports team members to resolve issues and identify appropriate matters for escalation
• Partners and/or directs vendors and internal business partners to facilitate timely claims resolution
• Supports workload surges and/or Catastrophe Operations as needed
• May act as an informal resource for team members with less experience

Senior Injury Claims Adjuster

• Processing new age claims according to guidelines
• Keeping claims under 30 days along with aging reports
• Submitting service requests for claim updates or needs
• Participating in team activities and assisting with processing 175-200 claims per day
• Logging claims for claims escalations and helping others reach team goals
• Researching resubmitted or corrected claims and pend appropriately
• Referring fee schedule, vendor contract, plan problems, or concerns to manager or senior processors
• Processing CMS 1500 and/or UB04 claims

Claims Processor

• Demonstrate the ability to independently and timely manage all aspects of the most complex, high-value claims while exhibiting a detailed knowledge of the claim, a well-reasoned analytical focus and a clear strategy for resolution
• Provide proactive communications to customers and business partners in the management and resolution of claims
• Respond to inquiries from customers and provide superior customer service
• Review and analyze multiple complex policies and coverage parts (including general liability and umbrella/excess liability)
• Write and articulate clear, concise and accurate coverage positions
• Conduct investigations regarding claims and/or lawsuits
• Effectively manage litigation and counsel, inclusive of litigation planning/budgeting, and proactively position claims for resolution
• Develop and persuasively articulate complex coverage, liability and damage assessments
• Provide detailed impactful recommendations to leadership
• Pursue and finalize coverage and liability risk transfer against other liable parties and insurance carriers
• Conduct complex negotiations and articulate coverage/liability positions
• Attend mediations and trials as necessary
• Proactively manage accurate expense, reserve and financial transactions
• Consistently maintain up-to-date claims metrics

Claims Specialist – Latent Bodily Injury

• Independently and timely manage all aspects of the most complex, high-value claims
• Provide proactive communications to customers and business partners in the management and resolution of claims
• Review and analyze multiple complex policies and coverage parts (including general liability, contractors professional liability and wrap-up policies)
• Write and articulate clear, concise and accurate coverage positions
• Conduct investigations regarding claims and/or lawsuits
• Effectively manage litigation and counsel, inclusive of litigation planning and budgeting
• Develop complex coverage, liability and damage assessments and persuasively articulate them to leadership
• Pursue and finalize coverage and liability risk transfer against other liable parties and insurance carriers
• Attend mediations and trials as necessary
• Proactively manage accurate expense, reserve and financial transactions
• Consistently maintain up to date claims metrics

Construction Defect Claims Specialist

• Communicating with claimants, employers, and various medical professionals through phone and e-mail to gather information regarding the Short Term Disability claim.
• Collaborating with fellow case managers, nurse case managers, and consulting physicians to make appropriate and timely claim determinations.
• Reviewing complex medical records and leveraging a variety of tools and resources to understand appropriate approval durations and future action planning.
• Completing accurate financial calculations consistent with company and state guidelines.
• Providing exceptional customer service and proactively recognizing customer needs and areas of opportunity.

Short Term Disability Claims Specialist

• In a remote call center environment, you will review, analyze, and process pharmacy claims with accuracy, timeliness, and adherence to company and regulatory standards.
• Identify discrepancies, investigate claim issues, and determine appropriate resolutions.
• Communicate effectively with pharmacies, providers, and internal teams to clarify information and resolve errors.
• Support audits and quality reviews by maintaining detailed, accurate claim documentation.
• Identify trends and share insights that can improve claim accuracy and efficiency.
• Uphold confidentiality and compliance with HIPAA and corporate policy standards.

Pharmacy Claims Representative 2

• Handle Commercial General Liability (CGL) and Business Owners Policy (BOP) claims from initial investigation through resolution
• Manage litigated and in-suit claims, partnering with defense counsel, experts and vendors throughout the litigation process
• Review policy language and determine coverage, liability, damages, and litigation strategy
• Develop and execute claim resolution plans that support timely and cost-effective outcomes
• Negotiate settlements with claimants, attorneys, and other involved parties
• Maintain accurate claim documentation in accordance with company and regulatory requirements
• Communicate with insureds, claimants, attorneys, vendors, and internal stakeholders

Complex Liability Adjuster – Litigated CGL, BOP Claims

• Investigate, evaluate, and adjust multi‑line liability claims (property damage & bodily injury) in accordance with CCMSI standards and state requirements.
• Manage claims involving commercial vehicles, trucking exposures, and third‑party liability.
• Determine coverage, assess liability, and develop defensible claim strategies.
• Review medical, legal, and vendor invoices for accuracy and reasonableness; negotiate discrepancies as needed.
• Establish, monitor, and adjust reserves in alignment with exposure and authority guidelines.
• Negotiate settlements with claimants, attorneys, and representatives in accordance with client expectations.
• Engage, coordinate, and manage defense counsel or other external vendors when appropriate.
• Identify and pursue subrogation opportunities.
• Maintain detailed and timely claim documentation, diary management, and financial reporting.
• Support excess reporting requirements and client communication needs.
• Deliver consistent, high‑quality service with professionalism and integrity.

Multi-Line Claims Adjuster – Commercial Auto, GL/BI

• Investigate and resolve claim rejections, denials, and payer edits identified before or after claim submission
• Review claim history, payer correspondence, medical records, authorizations, and supporting documentation to determine the cause of claim issues
• Correct billing, coding, demographic, authorization, and insurance-related claim errors as appropriate
• Process claim corrections, adjustments, resubmissions, and reconsideration requests in accordance with payer guidelines
• Perform payer research and communicate directly with insurance carriers to resolve claim processing issues
• Monitor assigned work queues and ensure timely resolution of outstanding claims
• Escalate complex reimbursement, coding, or compliance issues to senior team members
• Partner with A/R and Denials Management teams to resolve denied and underpaid claims
• Assist in preparing appeal documentation and supporting materials for denied claims
• Identify recurring denial patterns and communicate findings to the Senior Claims Resolution Coordinator
• Maintain accurate documentation of denial resolution activities and payer communications
• Support efforts to reduce preventable denials and improve reimbursement outcomes
• Work closely with the pre-billing team to identify and correct claim issues prior to submission
• Review claims for completeness and compliance with payer billing requirements
• Verify insurance information, authorizations, referrals, diagnosis coding, procedure coding, and modifier usage
• Collaborate with coding and clinical teams to obtain information needed for claim resolution
• Assist with reducing claim holds and billing delays
• Participate in routine claim quality reviews and internal audit activities
• Ensure claim corrections comply with payer regulations, organizational policies, and billing guidelines
• Support Revenue Integrity initiatives through accurate claim review and documentation
• Maintain knowledge of Medicare, Medicaid, Workers' Compensation, and Commercial payer requirements
• Adhere to HIPAA, CMS, and organizational compliance standards
• Maintain detailed documentation of claim investigations, resolutions, payer communications, and follow-up activities
• Track assigned workloads and resolution outcomes
• Assist with compiling information for denial trend reporting and operational reviews
• Provide feedback regarding workflow issues contributing to claim errors or payment delays
• Assumes other responsibilities as appropriate to the position and organizational needs

Claims Resolution Specialist

• Investigate automobile insurance claims to determine coverage, liability, and damages by reviewing policy terms, coverage limits, and exclusions.
• Communicate and collaborate with clients, claimants, agents, repair facilities, service providers, and attorneys to explain the repair and total loss processes.
• Appraise damaged vehicles and equipment using claims estimating software and prepare fair, accurate repair estimates virtually.
• Review and negotiate repair facility estimates; adjust supplements as necessary or assign independent adjusters when required.
• Manage the repair process from initiation through resolution and issue payments in accordance with authority guidelines.
• Complete total loss evaluations and explain salvage release requirements to clients and third-party claimants.
• Mitigate storage costs by coordinating vehicle transport to storage-free facilities and negotiating reduced rates with tow providers when applicable.
• Maintain accurate, thorough claim files, documentation, and activity logs in compliance with company procedures and regulatory standards.
• Identify potential subrogation opportunities, prepare supporting documentation, and submit demands to responsible parties or their carriers.
• Perform additional duties as assigned.

Auto Physical Damage Claims Specialist

• Proactively manages assigned claims caseload comprised of complex damages that require commensurate knowledge and understanding of claims coverage including potential legal liability
• Partners with vendors and internal business partners to facilitate complex claims resolution
• Investigates claim damages by conducting research from various sources, including the insured, third parties, and external resources
• Identifies coverage concerns, reviews prior loss history, determines and creates Special Investigation Unit (SIU) referrals, when appropriate
• Determines and negotiates complex claims settlement within authority limits
• Develops recommendations and collaborates with management for determining settlement amounts outside of authority limits
• Maintains accurate, thorough, and current claim file documentation throughout the claims process
• Utilizes platforms and tools to prepare claims estimates to manage complex property insurance claims
• Supports workload surges and catastrophe (CAT) response operations as needed, including mandatory on-call dates and potential evening, weekend, and/or holiday work outside normal work hours
• May be assigned CAT deployment travel with minimal notice during designated CATs
• Works independently solving complex problems with minimal guidance

Property Adjuster Specialist – Specialty Claims Team

• Determine compensability and/or coverage issues for loss time workers' compensation claims
• Effectively manage a caseload of loss time claims from numerous jurisdictions
• Negotiate and direct settlements under management's review
• Gather medical and factual evidence to determine compensability
• Direct outside investigation and handle litigation files within given authority
• Coordinate and maintain contact with claimants and/or their attorneys, outside investigators, and rehabilitation personnel as well as routine contact with insureds, account liaisons and medical providers

Workers' Compensation Claims Representative, Arizona/Colorado

• Handles claims, moderate to severe in scope, relative to homeowner’s property based on Claim Guidelines.
• Perform CAT duty as needed that will require occasionally working weekend hours, overnight hours, holiday hours (Federal and religious), etc.
• Follows standard practices and procedures in analyzing situations or data where answers can be readily obtained.
• Verifies/analyzes applicable coverage for the reported loss.
• Establishes 24-hour contact and maintain appropriate contact with all involved stakeholders throughout the life of the claim file.
• Investigates each claim by gathering information, conducting interviews, taking statements, conducting website research as needed, reviewing and analyzing reports and related bills.
• Identifies and addresses subrogation/contribution/SIU opportunities.
• Sets accurate/timely loss/expense reserves in compliance with Claim Guidelines.
• Evaluates, negotiates, and authorizes settlements with all stakeholders within designated authority.
• Selects, directs and manages Vendors/Counsel including approval of defense budgets.
• Negotiates directly with claimants and claimant attorneys upon receipt of critical information.
• Drafts correspondence, including but not limited to, coverage letters to stakeholders as required.
• Maintains resident/nonresident adjuster licenses as required.
• Works on problems of limited scope.
• Follows standard practices and procedures in analyzing situations or data from which answers can be readily obtained.
• Perform other duties as needed

Homeowners Property Claims Specialist

• Provides quality investigation and analysis to adjust claims at all levels to proper resolution
• Promotes the success of the organization through development and advancement of relationships with agencies, policyholders and employees
• Collaborate proactively with agents, policyholders and internal stakeholders on claims and book of business as needed
• Investigate losses, identify coverage, evaluate liability and damages
• Develop plan of action to proactively conclude claims, timely evaluate damages, engage other parties in negotiations and settle claims pursuant to guidelines and delegated authority
• Leverage past experience to review and analyze documents
• Establish and maintain proper reserves for each claim to accurately reflect the financial exposure
• Determine need for, identify and engage external resources as needed to execute proper resolutions while monitoring and controlling costs
• Review and interpret commercial insurance policies and accordingly communicate coverage issues verbally and in writing.

Senior Auto Physical Damage Claims Representative

• Investigate, negotiate and settle complex primary and excess policy claims including legal malpractice
• Investigate and analyze coverage under primary and excess professional liability insurance policies
• Manage litigation filed nationwide against insureds
• Communicate with underwriting as needed to manage claims
• Maintain and adhere to Markel’s guidelines and procedures
• Contribute and assist in the implementation of a wide range of initiatives
• Actively participate in the ongoing training and development of the claims examiners

Executive Claims Examiner

• The Senior Claims Examiner-Miscellaneous Professional Liability adjudicates assigned claims within given authority and according to Hiscox Claims Best Practices.
• Adjusts and resolves low to moderate professional liability claims that include litigated matters
• Accurately documents claim files with all relevant claim documentation, correspondence and notes in compliance with company policies and applicable regulatory authorities
• Heavy customer facing role. Must have confident communication skills.
• Communicates effectively to resolve matters directly with claimants, and or claimant attorneys
• With minimal supervision, drafts coverage letters, including reservation of rights and denial letters
• Reviews and analyzes claims in order to determine appropriate and timely reserving per Hiscox Claims Best Practices
• Identifies emerging exposures and claims trends
• Manages defense counsel as necessary in defending litigated matters
• Identifies suspected fraudulent claims and tracks with Special Investigations Unit
• Participates in Claims Projects, as needed

Senior Claims Examiner – MPL

• Investigate and resolve Homeowners claims of moderate complexity in a prompt and efficient manner.
• Document with photographs, measurements, recorded interviews as needed, write a repair estimate to capture damages, and complete thorough file notes.
• Ability to use imagery and advanced video technology to collaborate with onsite vendors and insureds to identify damage and write damage estimates from a virtual setting.
• Compare facts gathered during the investigation against the policy to determine coverage of claim; extend or deny coverage as appropriate.
• Establishes reserve amounts within prescribed settlement authority limit and negotiates settlement of claims; recommends claims which exceed personal authority limit to supervisor for approval.
• Responsible for effectively and timely communicating with insureds and /or their representatives to resolve issues and ensure customer satisfaction.

Property Claims Examiner II – Wind/Hail

• Provide quality investigation and analysis to adjust claims of low complexity/severity
• Collaborate and communicate with agents, policyholders and internal stakeholders on claims and book of business
• Investigate losses, identify coverage, determine compensability, review and analyze documents and legal pleadings
• Develop plan of action to proactively conclude claims, timely evaluate damages, engage other parties in negotiations and settle claims pursuant to guidelines
• Establish and maintain proper reserves for each claim to accurately reflect the financial exposure
• Collaborate with manager and counsel to manage litigated claims
• Review and interpret commercial insurance policies and accordingly communicate coverage issues verbally and in writing

Claims Specialist jobs in Arizona

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