Claims Specialist

• The position of Care Advocate will play a leading role in developing an innovative digital product strategy based off your deep expertise and knowledge of the long-term care needs of the aging in your market.
• You will be part of a team delivering concierge services care-seekers and care-managers including but not limited to Caregiver support and Education.
• Conducting consultations with older adults and caregivers on aging services and supports providing support and guidance on the caregiving journey.
• Unlike other traditional Care Advocacy roles, your responsibilities will not stop there but will extend to working with digital product teams to help infuse your patient-centered knowledge into the design process and provide feedback that will help create incredible digital user experiences for millions of care-seekers and care-managers at a tremendous scale.
• This role will provide Subject Matter expertise on the local and state level programming and resources for aging adults and their caregivers.
• This role will provide education and resources to aging individuals seeking assistance with care options and navigating challenges.
• Intensive case management experience and crisis intervention.
• Approach problem-solving with a human-centered lens.
• Regular document key and frequent needs of users and report qualitative data (such as quotes and anecdotal stories that representative of user needs) and quantitative data (such as frequency of user needs and trends in gaps in local care environments and resources) to the digital product and design teams.
• Bring deep understanding of landscape and individual aging and long-term resources, facilities, organizations, agencies, and referral sources to help marketing team reach key partnerships and potential consumers who would benefit from our digital products.
• Report back to product and design teams opportunities for improvement of the digital products based off of user feedback.
• Review new product features before they are released to consumers to identify improvements or potential issues to proactively improve user experience.

Associate Claims Clinical, Care Advocacy

• Manage the claims reporting process for agency clients.
• Report claims to the appropriate carrier and maintain records in the agency management system by documenting claim actions in accordance with established procedures.
• Follow up on claims to obtain the specific adjuster and claim number relevant to the reported loss.
• Notify appropriate parties when a claim is processed with carrier, providing accurate and timely claim information.
• Continuously monitor claims until claims are closed by the insurance carrier.
• Report any potential issues with a claim to the client's Account Manager and Producer, escalating to management as needed.
• Prepare reports by collecting and summarizing information as requested by management.

Commercial Lines Claims Specialist

• Investigates, evaluates, negotiates, and resolves assigned claims
• Handles the most complex claims with minimal manager oversight
• Establishes and maintains positive relationships with customers
• Assists in building business relationships with agents, insureds and partners
• Develops and mentors other associates
• Assists leadership in training and resources development
• Maintains proper reserving through proactive investigation
• Assists other departments with investigations as required

Claims Representative, Casualty Large Loss, Auto Injury

• 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

• Manage lost time and medical only Workers' Compensation claims.
• Evaluates and establishes an action plan to manage medical and indemnity benefits associated with injury and occupational disease claims.
• Decides the outcome of the claim using sound judgment by applying established policy, procedures, regulations and guidelines.
• Gathers facts by conducting interviews with all involved parties and considers all the elements of the claim prior to issuing a decision.
• Determines eligibility of indemnity and medical benefits once salary information and medical treatment plans have been secured and processed.
• Utilize proactive reserving behaviors to ensure adequate case reserves.
• Consults with assigned claim director, return to work specialists, nurse case managers, and internal/external medical professionals.
• Works collaboratively with the injured worker, employer, outside counsel, and health and rehabilitation professionals to manage the claims costs.

Lost Time Claims Adjuster – Workers' Compensation

• Leverage your Pharmacy Claims Experience to manage and resolve claims efficiently, ensuring our clients get the support they need.
• Be a vital part of a team that’s dedicated to enhancing patient care through meticulous claims management and customer service.
• Manages and identifies a portfolio of rejected pharmacy claims to ensure maximum payer reimbursement and timely billing to eliminate financial risks.
• Researches, analyzes and appropriately resolves rejected claims by working with national Medicare D plans, third party insurance companies and all state Medicaid plans to ensure maximum payer reimbursement adhering to critical deadlines.
• Ensures approval of claims by performing appropriate edits and/or reversals to ensure maximum payer reimbursement.
• Monitors and resolves at risk revenue associated with payer set up, billing, rebilling and reversal processes.
• Works as a team to identify, document, communicate and resolve payer/billing trends and issues.
• Reviews and works to convert billing exception reports to ensure claims are billed to accurate financial plans.
• Prepares and maintains reports and records for processing.
• Performs other tasks as assigned.

• Accurately performs billing and collections for multiple facilities for all payors.
• Provide professional and technical support to staff across multiple departments.
• Respond to inquiries from insurance carriers, patients, and family members regarding billing and account balance questions.
• Monitor and review financial systems to ensure accurate revenue recognition and maintain appropriate accounts receivable levels aligned with payer mix and acuity.
• Collaborate with Utilization Management departments to ensure pre-certifications, authorizations, and appeals are completed accurately and on time.
• Perform effective and timely follow-up on insurance claims to secure appropriate reimbursement.
• Analyze explanations of benefits (EOBs), remittances, and explanations of payment (EOPs) to identify discrepancies or underpayments.
• Research and resolve claim issues
• Prepare, submit, and track appeals for denied claims through resolution.
• Prepare for and actively participate in weekly Accounts Receivable (AR) meetings.

Claims Analyst

• Manage complex insurance claims in a key-pointed area, work independently, schedule appointments for vehicle inspections, and travel throughout your key-point territory.
• Conduct thorough coverage investigations, including fire, theft, false pretense claims, and coverage decisions for floor-planned units.
• Prepare accurate damage estimates using computerized estimating systems (e.g., Mitchell Connect) to establish the cost of repairs.
• Lead subrogation investigations, salvage disposal, and fraud investigations.
• Perform loss prevention reviews and provide essential dealer training activities.
• Remain on-call for CAT/Storm losses and be prepared for extensive travel away from home for extended periods of time.

Catastrophe Auto Claims Adjuster

• Investigates and adjudicates claims within designated authority, ensuring compliance with appropriate statutory laws.
• Verifies coverage, establishes and maintains reserves, secures recorded statements, drafts and processes correspondence, reports and records.
• Obtains additional information as required to determine liability.
• Documents claim files and facilitates processing of claims in collaboration with other departments.
• Establishes contact with all parties involved in the claim in accordance with ERIE’s expectations.
• Evaluates and negotiates claims, recognizes subrogation opportunities, and initiates action.
• Responds to inquiries from Policyholders, Agents, insurance carriers, claimants, assigned experts and others.

Claims Specialist jobs in Kentucky

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