United States onlyAbout Us
At Davies, we get it...you are not just looking for a job, you are looking to build a life and a career. We believe in our people and realize that our success is a direct result of creating a learning atmosphere, leadership opportunities, and promoting from within. We believe that engaging in corporate social activities and working together as a team is a vital part of the Davies culture.
With a multinational global team, Davies Group is a specialist professional services and technology firm working in partnership with leading insurance, highly regulated, and global businesses. At Davies Group, we help clients to manage risk, operate core business processes, and to transform and grow. We deliver operations, consulting and technology solutions across the risk and insurance value chain, including excellence in claims, underwriting, distribution, regulation, customer experience, human capital, transformation, and change management.
Are you looking for a company that is Dynamic and Innovative where the employees are Connected and Succeed Together? If so, Davies may just be the right choice for you.
Job Overview
Northshore International Insurance Services is looking for a Claims Director to ensure compliance, accuracy and efficiency in claims processing while also identifying opportunities for improvement and cost savings. You will serve and meet the HMO/Provider Excess, Stop Loss and Reinsurance Claims needs of our clients. Reporting to the Assistant Vice President, you will audit and review managed care and provider excess provider agreements as well as health plan/TPA contracts, review employer stop loss specific and aggregate excess claims and adjudicate claims accordingly while acting as the point of contact for the client(s).
To be successful in this role, you need to possess a deep understanding of claims adjudication processes, particularly in the areas of employer stop loss specific and aggregate excess claims, have exceptional analytical skills with the ability to interpret complex claims data and identify trends and patterns, and be well versed in self-insured and managed care concepts. You must have a minimum of 2 years medical claims management experience; prior experience in auditing, reviewing, and adjudicating 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; knowledge of first dollar medical and pharmacy claims, claim processing platforms, and medical terminology and coding, and knowledge of CMS regulations, Medicare and Medicaid fee schedules, and Medicare and Medicaid programs for state level agencies. Additionally, you will need to have superb organizational skills with meticulous attention to detail and a commitment to accuracy and quality, excellent effective communication and negotiation abilities to liaise with internal and external stakeholders, and strong Microsoft Office Suite skills especially Word and Excel. This role is a full-time, home-based position.
Responsibilities and Duties
Auditing and Review
- Conduct thorough audits and reviews of managed care and provider excess provider agreements to ensure compliance with contractual terms and industry regulations
- Evaluate health plan/TPA contracts to verify adherence to established guidelines and standards
- Identify discrepancies, errors, or potential areas of risk and develop strategies for resolution or mitigation
Claims Adjudication
- Oversee the adjudication process for employer stop loss specific and aggregate excess claims, ensuring accuracy and timeliness
- Collaborate with claims examiners and analysts to resolve complex claim issues and disputes
- Implement best practices and quality assurance measures to enhance claims adjudication efficiency and effectiveness
Compliance and Regulatory Oversight
- Stay abreast of industry trends, regulatory changes, and best practices related to claims management and contract administration
- Ensure compliance with relevant state and federal regulations, including HIPAA, ACA, and ERISA
Strategic Planning and Analysis
- Analyze claims data, trends, and patterns to identify opportunities for cost containment, process improvement, and risk mitigation
Other
- Consistent production of claim reports and findings
- Maintain communication with clients and intermediaries on a regular basis for assigned accounts
- Comfortable working solo or collaborating with clients, intermediaries, and peers
- Perform peer editing to validate the work of others
- Assist with aspects of training
- Exhibit company values of We are Dynamic, We are Innovative, We are Connected, and We Succeed Together
- Perform other duties as assigned
Experience and Qualifications
Required
- Minimum 2+ years medical claims management experience
- Experience in auditing, reviewing, and adjudicating 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
- In-depth knowledge of managed care and provider excess provider agreements, health plan/TPA contracts, and relevant regulatory requirements
- Working knowledge of first dollar medical and pharmacy claims, claim processing platforms, and medical terminology and coding
- Well versed in self-insured and managed care concepts
- Knowledgeable of CMS regulations, Medicare and Medicaid fee schedules, and Medicare and Medicaid programs for state level agencies
- Exceptional analytical skills with the ability to interpret complex claims data and identify trends and patterns
- Superb organizational skills
- Detail-oriented with a commitment to accuracy and quality
- Excellent communication and negotiation skills, with the ability to effectively liaise with internal and external stakeholders
- Strong Microsoft Office Suite skills, especially Word and Excel
Desired
- Bachelor's degree in Business Administration, Healthcare Administration, or related field
- Certified Professional in Healthcare Risk Management (CPHRM) or Certified Professional in Healthcare Quality (CPHQ) certification, or other credentialing (HIA, MHP)
Knowledge, Skills, and Abilities
- Proactive, independent, and takes initiative with consistent follow through
- Superior time management skills with capability of working with and meeting deadlines
- Exceptional capability to multi-task and prioritize with excellent organizational and documentation skills in a fast-paced, dynamic work environment
- Excellent team player with interpersonal skills
- Capable of working collaboratively and independently with minimal supervision
- Exhibit discretion with sensitive and confidential information
- Display a comfort level working with key people at all levels within an organization
Essential Requirements
- Must have US work rights
- Must speak English
- Prior medical claims management experience, specifically in managed care and provider excess provider agreements, health plan/TPA contracts, and relevant regulatory requirements
- Proficient in processing first dollar medical and pharmacy claims; utilizing claim processing platforms, and applying medical terminology and coding
- Familiar with self-insured and managed care concepts alongside knowledge of CMS regulations, Medicare and Medicaid fee schedules and programs for state level agencies
- Exceptional analytical skills for interpreting complex claims data and identifying trends/patterns
- Superb organizational skills with meticulous attention to detail and a commitment to accuracy and quality
- Effective communication and negotiation abilities to liaise with internal and external stakeholders
- Proficiency in Strong Microsoft Office Suite skills, especially Word and Excel
Other Duties
This job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities required of the individual for this job and is subject to change with or without notice.
Diversity and Inclusion
Davies is committed to being a diverse and inclusive workplace. We welcome candidates of all genders, gender identity and expression, neurodiversity, sexual orientation, disability, physical appearance, body size, race, age, nationality, and belief (or lack thereof).
Rewards and Recognition
We embrace innovation and run an annual competition available for all colleagues to submit their ideas. The top finalists travel to the current year’s competition site where they pitch their ideas to our investors. The winner receives funding to bring their idea to life and the runners up receive a reward for their involvement. Some of our teammates have moved across into brand new positions to further develop their ideas/projects!
Benefits
- Annual Billable Hour Bonus
- Medical, dental, and vision plans
- 401k plan with employer matching
- Paid Time Off, Sick Leave, and Paid Holidays
- Life insurance, short term, and long-term disability plans
- Amazing Executive and Senior leadership as well as fabulous teammates
Position Type, Work Environment and Physical Demands
This is a home-based, full time, salaried, exempt position that predominantly operates remotely from a professional home-based office environment routinely using standard office equipment such as computers, phones, printers, photocopiers, and scanners and requires prolonged periods of sitting at a desk while working on a computer. While performing the duties of this job, the individual will be required to regularly hear and talk. This is a largely sedentary role requiring the ability to sit at a desk, reach outward, use a phone, have use of fingers to operate office equipment such as a keyboard, mouse, phone, printer, copier, and to reach above the head, bend, or stand, as necessary.
Location
Northshore International Insurance Services is currently able to support employees residing in the following US locations AZ, IA, IL, MA, ME, MN, NH, NJ, NY, OH, PA, TN, and TX. If you live in—or are willing to relocate at your own expense to—any of the listed locations, we look forward to your application! If there is a required or preferred location for an open role, it will be listed in the job description. Should your state not be listed, please visit https://davies-group.com/location/ to locate a subsidiary near you.
