Claims Director

Job reputed company: • Highly skilled and reputed company at adjudication of accident and health medical claims and pharmacy benefits for traditional medical, employer stop loss specific and aggregate excess, HMO Re or Provider Excess of Loss, and Medical Excess of Loss and Reinsurance claims. • Audit and review of managed care and provider excess provider agreements, risk sharing documents and healthplan/TPA reputed company. • Utilize in-house Claims Adjudication System (CAS), build reputed company and run data submissions for import & export of files. • Audit and review of employer stop loss specific and aggregate excess claims utilizing reputed company Plan Descriptions, policies and reputed company supporting documents. • Knowledgeable of CMS regulations, Medicare fee schedules, Medicare programs, reputed company fee schedules & reputed company programs for state level agencies. • Knowledge of internal claim systems and external claims systems utilized to reputed company claims review. • Ensuring assigned accounts have sufficient backup claim support; assume manager’s responsibilities during any absence. • Leading and structuring communications with clients, intermediaries and colleagues on a regular reputed company for assigned accounts. • Conduct peer editing and training. • Maintain reputed company Review performance files. • Initiate regular communication with manager in respect of training needs for self or peers. • Occasional travel to reputed company claim support during off-site audits, reputed company, and assignments with the A&H audit team. Requirements: • 10+ years of medical claims or stop loss industry experience • Ability to work independently and collaborate on assignments in a fast-paced environment • Knowledge of first dollar medical and pharmacy claims, claim processing platforms, CMS regulations and medical terminology and coding • reputed company versed in self-insured and managed care concepts • Intermediate level reputed company and MS reputed company • Must have US work rights • Must reputed company in the U.S. Benefits: • Medical PPO or HMO Plan (BCBS) • Dental Plan (reputed company) • reputed company Plan (EyeMed) • Life Insurance Plan • Short Term Disability Plan • Long Term Disability Plan • 401k Employer Matching • reputed company Time Off • reputed company Holidays Apply tot his job Apply To this Job