Claims Director directs and oversees the operations of an insurance claims department to meet operational, financial, and service requirements. Establishes policies and procedures for the administration of insurance claims for personal, property, or casualty loss based on coverage, appraisal, and verifiable damage. Being a Claims Director is responsible for the strategic processing and payment of claims. Maintains up-to-date- knowledge of legislation, regulations, and industry events which pertain to insurance claims. Additionally, Claims Director provides expert guidance and consultation to staff on the most complex claims. Requires a bachelor's degree. Typically reports to top management. The Claims Director manages a departmental sub-function within a broader departmental function. Creates functional strategies and specific objectives for the sub-function and develops budgets/policies/procedures to support the functional infrastructure. To be a Claims Director typically requires 5+ years of managerial experience. Deep knowledge of the managed sub-function and solid knowledge of the overall departmental function. (Copyright 2024 Salary.com)
Description
JOB SUMMARY
This job is responsible for screening, reviewing, evaluating online entry, correcting errors and / or performing quality control review and final adjudication of paper / electronic claims.
Determines whether to return, deny or pay claims following organizational policies and procedures. Reviews processed claims and inquiries to determine corrective action including adjusting claims as necessary and takes the corrective action steps using enrollment, benefit and historical claim processing information;
may coordinate benefits and interact with customers. Responsible for the timely and accurate completion of claims adjustments which could be a result of internal / external audits, member / provider phone calls, other insurance information received, appeals, and system changes, etc.
provides technical assistance in researching and resolving inquiries.
ESSENTIAL RESPONSIBILITIES
Maintains accurate records, including timekeeping records and attends all required training classes.
Other duties as assigned or requested.
EDUCATION
Required
High School Diploma / GED
Substitutions
None
Preferred
None
EXPERIENCE
Required
1 year of related experience
Preferred
LICENSES or CERTIFICATIONS
Required
None
Preferred
None
SKILLS
Language (Other than English) :
None
Travel Requirement : 0% - 25%
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Office-based
Teaches / trains others regularly
Never
Travel regularly from the office to various work sites or from site-to-site
Never
Works primarily out-of-the office selling products / services (sales employees)
Never
Physical work site required
Lifting : up to 10 pounds
Constantly
Lifting : 10 to 25 pounds
Occasionally
Lifting : 25 to 50 pounds
Never
Pay Range Minimum : $16.50
$16.50
Pay Range Maximum : $22.20
$22.20
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation / gender identity or any other category protected by applicable federal, state or local law.
Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation / gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities / Women / Protected Veterans / Disabled / Sexual Orientation / Gender Identity ()
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