Claims Specialist

• Analyze New York Lost-Time Workers Compensation claims on behalf of clients to determine benefits due
• Ensure ongoing adjudication of claims within service expectations, industry best practices, and client service requirements
• Analyze and process claims through action plans by investigating and gathering information to determine claim exposure
• Negotiate claim settlements within designated authority
• Communicate claim activity and processing with claimants and clients
• Report claims to the excess carrier and respond to direction requests professionally and timely

Workers Compensation Claims Examiner, NY Jurisdiction Experience

• Reassure customers and offer solutions with empathy and care
• Guide policyholders through their coverage and the steps to get back on the road safely
• Manage incoming calls
• Collect accident facts and statements from involved parties
• Investigate claim details
• Assist customers in getting back on the road
• Resolve customer concerns and ensure a positive experience
• Drive customer satisfaction through meaningful interactions

• Submit accurate institutional (UB-04) and professional (CMS-1500) claims to commercial and government payers
• Review and resolve claim edits, billing errors, clearinghouse exceptions, and rejections
• Submit corrected claims and ensure successful claim transmission to payers
• Verify patient eligibility and resolve coverage or demographic discrepancies prior to claim submission
• Communicate with insurance carriers, patients, providers, and internal teams to resolve billing issues
• Complete billing reviews, post splint charges, and enter charges into the DOL and Claim Connect portals
• Monitor claims processing inboxes and follow up on outstanding clearinghouse responses
• Navigate the Raintree EMR system to resolve claim issues and document account activity
• Meet departmental productivity and quality standards while maintaining compliance with HIPAA and other applicable regulations
• Stay current on payer policies and billing guidelines
• Perform other duties and special projects as assigned

Hospital Billing & Claims Specialist

• Manage an inventory of low to moderate complexity and exposure commercial claims
• Verify policy coverage, gather necessary information, maintain file documentation and authorize disbursements within authority limits
• Interact professionally with insureds, claimants and business partners to support customer satisfaction and meet quality and cycle time standards
• Provide regular, timely updates and respond to inquiries and requests for information
• Verify coverage and establish timely and adequate reserves by reviewing policy language and estimating potential claim valuation
• Conduct investigations, take recorded statements and work with experts to determine liability and compensability
• Collaborate with internal and external partners, suppliers and experts to facilitate best claim outcomes
• Negotiate settlements and escalate claims to management as appropriate
• Manage expenses through timely and accurate claim resolution and resource oversight
• Identify subrogation, salvage and potential fraud opportunities and make appropriate referrals
• Maintain compliance with state and local regulatory requirements
• Perform additional duties as assigned

Workers Compensation Claims Representative

• Develop, implement, monitor, and take primary responsibility for handling a broad range of New York workers compensation insurance claims for NYSEG and RG&E
• Administer Insurance Programs and the renewal process; identify coverage gaps and recommend insurance program modifications
• Coordinate preparation of insurance renewal applications
• Administer workers compensation programs, including processing claims, determining third-party recovery potential, overseeing light duty and return-to-work programs, monitoring salary continuation and disability payments, making reserve recommendations, attending hearings, and reviewing claims
• Process and reconcile retained loss cost invoices and records
• Administer referrals, communications, and information among employees, supervisors, and a workers compensation case management vendor
• Negotiate and settle claims in accordance with company policy
• Work with legal staff and outside counsel on larger claims
• Assist Human Resources with FMLA, ADA, OSHA, and employee claims matters
• Support cost reduction goals through improved methods, procedures, and insurance program changes
• Oversee workers compensation-related software applications, including Stars and SAP
• Maintain OSHA records and loss reports

Claims Specialist jobs in New York

Workers Compensation Claims Examiner, NY Jurisdiction Experience