Accident and Health Senior Claims Specialist (Provider XS/ESL)
Core
Senior claims handling expertise for Accident and Health products including Managed Care, HMO, Medical Excess, Provider Excess, and Employer Stop Loss, overseeing both in-house adjudication and Third-Party Administrators (TPAs).
Role type
Senior IC Accident and Health Claims Specialist
Builds
Claims adjudication, audit reports, and oversight procedures for MGUs and TPAs
Domain
Specialty Insurance / Accident and Health
Deliverable
client delivery
Required skills
MGU oversight, Stop Loss claims, Provider Excess claims, Managed Care claims, TPA auditing, ERISA compliance, exposure evaluation, reserving
Preferred skills
Power BI, data analysis, negotiation
Technologies
Microsoft Office Suite, Power BI
Responsibilities
Conduct annual and desk audits of MGUs and TPAs, review claims exceeding authority thresholds, coordinate responses to complaints and attorneys, monitor oversight procedures for MGUs and TPAs, gather and analyze monthly reporting data, partner with underwriting and actuarial teams, lead special projects
Seniority
Senior, hands-on IC