Claims Specialist

Old Republic Accident & Health; United States; On-site; USD 65,000 - 90,000; Full time

Job summary

Old Republic Accident & Health is seeking a collaborative Claims Specialist to join our fast-growing team. You will process and adjudicate stop-loss claims, make reimbursement decisions, and ensure compliance with applicable laws and policy documents.

Responsibilities include reviewing codes, analyzing claim data, and partnering with underwriters, clinicians, and brokers to meet client needs and maintain high service levels. A Bachelor’s degree and 2–5 years of relevant experience are preferred.

Qualifications

• 2-5 years of stop-loss claims reimbursement experience.
• Experience with claims software (Connexure or UGAN) and CPT and ICD coding knowledge is required.
• Demonstrated ability to manage multiple high-priority projects concurrently, effectively set priorities, and consistently meet tight deadlines.
• Strong communication and interpersonal skills with the ability to effectively convey information at all levels, both verbally and in writing.
• Ability to manage tasks autonomously while also supporting team goals.

Responsibilities

• Process and adjudicate stop loss claims to ensure timely and accurate resolutions.
• Make accurate reimbursement decisions based on policy documents, plan details, and cost containment strategies.
• Authorize and process payment, partial payment, or denial of claim based upon individual investigation and analysis.
• Review billed procedure and diagnosis codes on claims for billing irregularities.
• Ensure compliance with laws and regulations.
• Develop quantitative analyses of claims issues.
• Analyze claim data and trends to identify areas for improvement in the claims process.
• Collaborate with underwriting, clinical, and business development teams to address client needs and provide exceptional service.
• Build and maintain strong relationships with TPAs, vendors, MGUs, brokers, and other stakeholders to ensure high levels of customer satisfaction.

Skills

Stop-loss claims

CPT coding

ICD coding

Communication

Multitasking

Education

Bachelor's degree in business or related field

Tools

Connexure

UGAN

Job description

Old Republic is a leading specialty insurer that operates diverse property & casualty and title insurance companies. Founded in 1923 and a member of the Fortune 500, we are a leader in underwriting and risk management services for business partners across the United States and Canada. Our specialized operating companies are experts in their fields, enabling us to provide tailored solutions that set us apart.

Position Overview:

Old Republic Accident & Health is seeking a collaborative and detail-oriented Claims Specialist to join our fast-growing team. This role is crucial in ensuring accuracy on policy documents, making prompt decisions based upon detailed analysis of complex issues, and partnering effectively with our external stakeholders. The ideal candidate will have a background in claim reimbursement, with the ability to recognize and resolve claim issues while following compliance guidelines.

Essential Job Functions:

• Process and adjudicate stop loss claims to ensure timely and accurate resolutions.
• Make accurate reimbursement decisions based on policy documents, plan details, and cost containment strategies.
• Authorize and process payment, partial payment, or denial of claim based upon individual investigation and analysis.
• Review billed procedure and diagnosis codes on claims for billing irregularities.
• Ensure compliance with laws and regulations.
• Develop quantitative analyses of claims issues.
• Analyze claim data and trends to identify areas for improvement in the claims process.
• Collaborate with underwriting, clinical, and business development teams to address client needs and provide exceptional service.
• Build and maintain strong relationships with TPAs, vendors, MGUs, brokers, and other stakeholders to ensure high levels of customer satisfaction.

Qualifications:

• 2-5 years of stop-loss claims reimbursement experience. Knowledge of relevant insurance regulations preferred.
• Experience with claims software (Connexure or UGAN) and CPT and ICD coding knowledge is required.
• Demonstrated ability to manage multiple high-priority projects concurrently, effectively set priorities, and consistently meet tight deadlines.
• Strong communication and interpersonal skills with the ability to effectively convey information at all levels, both verbally and in writing.
• Exceptional problem-solving and sound decision-making abilities.
• Ability to manage tasks autonomously while also supporting team goals.
• Bachelor’s degree in business or related field.

ORI is an Equal Opportunity Employer. ORI provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.