Claims Specialist

• Responsible for managing complex workers compensation claims
• Ensure timely adjudication of claims within company standards and regulatory requirements
• Contact with employers, injured workers, and medical providers within designated timelines
• Documentation of claims and wage information
• Timely completion of claims determinations and payments
• Manage legal aspects of claims and assign attorneys
• Supervise claims assistants and coordinate assignments
• Monitor claims for reporting requirements

Indemnity Claims Adjuster

• 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 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

• Support the Clinical Research billing and account review needs of the Providence Health System
• Review charges, processing and tracking of ongoing research-related clinical billing
• Regularly review research-related billing process for accuracy and compliance

• Investigate and evaluate claims to determine coverage, compensability, and liability
• Conduct thorough investigations, including interviews with claimants, employers, and witnesses
• Obtain and review relevant documentation (e.g., medical records, police reports, employment records)
• Develop and implement strategic action plans for claim resolution
• Prepare and present clear, accurate, and timely reports to clients and carriers
• Manage EDI reporting and CMS/Section 111 compliance requirements
• Negotiate settlements with claimants and legal representatives to achieve fair resolutions
• Oversee litigation activities, ensuring effective cost control and alignment with account requirements
• Utilize approved vendor partners to support claims handling activities
• Handle complex claims, including catastrophic losses and sensitive issues
• Respond promptly and professionally to client inquiries and communications
• Maintain compliance with all licensing and regulatory requirements
• Stay current with industry trends, legal updates, and best practices through ongoing training
• Support team development by mentoring and sharing expertise with colleagues, as needed
• Perform other duties as assigned

Senior Workers' Compensation Claims Adjuster

• Investigate and confirm the facts of loss for automobile accidents.
• Determine coverage, liability, damages and adjust and negotiate claims within limit of authority.
• Handle investigation regarding auto claims (coverage, liability and damages).
• Review, evaluate, and negotiate basic injury claims if handled.
• Recognize and identify body parts of a vehicle and understand other potential property damage.
• Identify customer needs and work to meet those needs using appropriate customer service skills.
• Determine subrogation or fraud potential and how to handle.

Claims Specialist jobs in New Mexico

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Indemnity Claims Adjuster

Claims Resolution Specialist

Property Claims Examiner II – Wind/Hail

Claims Specialist

Senior Workers' Compensation Claims Adjuster

MD Claims Adjuster