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

• Complete field inspections and related responsibilities such as reading maps and aerial photos
• Measure fields, storage bins, and discuss findings of crop loss with farmers
• Convey complex regulations and interpretations to claimants, agents, and industry people
• Perform fact finding regarding crop damage and record information
• Transmit loss information to determine potential indemnities
• Complete claim reviews and audits
• Ensure legal compliance by maintaining a strong working knowledge of regulatory and company policies
• Participate in projects as needed

Crop Claims Field Adjuster I

• 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.
• 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.
• 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.
• Monitor and communicate InterPlan performance metrics (IPP).
• Track quality and productivity metrics; lead improvement initiatives.
• 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.

Lead Claims Bluecard Analyst

• 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

• The Investigative Specialist reviews complex and often unique claims to assess their validity and ensure accurate outcomes.
• In this role, you will investigate and verify the facts of loss for a range of automobile claims, from basic to advanced scenarios.
• Leveraging your auto claims adjusting experience, you will evaluate coverage, determine liability, and assess damages.
• You will also take ownership of the claims process by making informed decisions and effectively negotiating settlements.
• Every claim presents a new challenge.

Claims Investigative Specialist

• Reviews claims and extracts information for processing
• Assists beneficiaries and family members with questions and claim status through an incoming call line
• Collects information and processes death claims
• Verifies, corrects, and completes claims information by telephone, letter, or personal contact
• Conducts investigations and gathers supporting documentation on claims
• Calculates benefits payable
• Approves (to a specified amount) or denies claims in accordance with established procedures

Senior Claims Examiner – Virtual

• Ensures patient account and claim information contains comprehensive and accurate data
• Provides timely billing and optimal reimbursement for services

Claims Specialist – Other Fiscal Services

• Investigate automobile accidents involving bodily injury
• Assess coverage, liability, and damages
• Provide exceptional customer service through calls, emails, and texts
• Engage in negotiation processes to reach fair settlements
• Support claimants throughout the vehicle restoration process

Claims Resolution Adjuster

• Managing claim files on behalf of clients for claims service business operations.
• Handling and supervision of complex and litigated claims with authority for settlement.
• Responsible for the investigation of coverage, liability, and damages.
• Negotiating with claimants, attorneys, and other insurance carriers throughout the life of a claim.
• Review lawsuits and formulate a plan of action with the assigned attorney.
• Monitor progress and keep the insured informed.
• Ensure all information is documented in the claim file.
• Communicate with clients to discuss claims and recommend strategies to reduce overall exposure.

Senior Claims Adjuster

• 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

• 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.
• Reports incidents involving theft, fraud, or arson to appropriate state and industry agencies.
• Perform duties independently, with work directly impacting management outcomes.
• Acts as a company representative in public interactions, maintaining a professional demeanor consistent with management standards.
• Engages 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.
• Performs additional duties as assigned.
• Promotes safety at all times and complies 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 23 days.

Field Property Claims Adjuster

• To analyze mid- and higher-level workers compensation claims to determine benefits due;
• to ensure ongoing adjudication of claims within company standards and industry best practices;
• and to identify subrogation of claims and negotiate settlements.
• Manage workers compensation claims determining compensability and benefits due on long term indemnity claims, monitors reserve accuracy, and files necessary documentation with state agency.
• Develop and manage workers compensation claims' action plans to resolution, coordinates return-to-work efforts, and approves claim payments.
• Approves and processes assigned claims, determines benefits due, and manages action plan pursuant to the claim or client contract.
• Manages subrogation of claims and negotiates settlements.
• Communicates claim action with claimant and client.
• Ensures claim files are properly documented and claims coding is correct.
• May process complex lifetime medical and/or defined period medical claims which include state and physician filings and decisions on appropriate treatments recommended by utilization review.
• Maintains professional client relationships.

Claims Specialist jobs in Washington

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