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, and Stop Loss, overseeing Third-Party Administrators (TPAs) and Managing General Underwriters (MGUs).
Role type
Senior IC claims specialist (Accident & Health)
Builds
Claims adjudication, audit reports, and oversight procedures for MGUs and TPAs
Domain
Insurance (Accident & Health, Specialty Lines)
Required skills
MGU oversight, Stop Loss claims, Provider Excess claims, HMO managed care claims, TPA auditing, ERISA knowledge, 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 MGU and TPA authority thresholds; Coordinate responses to complaints and attorneys; Monitor and enforce oversight procedures for MGUs and TPAs; Gather, analyze, and interpret monthly reporting data to identify trends; Partner with underwriting and actuarial teams to communicate claim trends.
Seniority
Senior, hands-on IC