Claims Administrative Specialist

The Doctors Company•Napa, CA

36d•$46,436 - $60,947•Hybrid

About The Position

The Doctors Company is seeking an experienced Claims Administrative Specialist to support our Claims team. This is a hybrid opportunity based in Sherman Oaks, CA or Napa, CA. The Claims Administrative Specialist is responsible for communication with members and callers to obtain necessary written documentation to create an electronic claim file. You will also provide clerical, administrative, and technical assistance to the assigned claims staff; maintain specific, timely, accurate coding and file updates to support data warehouse searches for claims processing and TDC research projects. This position supports employees, member physicians, agents, brokers, vendors, defense lawyers, administrators, and patients.

Requirements

Experience in insurance or healthcare industry preferred
Excellent oral and written communication skills
Demonstrates organizational skills and attention to detail
Strong customer service skills and ability to work on a high performing team
Proficiency within Microsoft suit of products, including Word, Excel, and Outlook
Ability to follow departmental procedures with a high degree of accuracy and detail
Ability to prioritize workload to meet pertinent deadlines and response dates
Ability to handle confidential personal health information in accordance with company policy and PHI rules & regulations
Ability to support internal and external stakeholders with diverse backgrounds and personalities

Responsibilities

Maintains a broad-based understanding of the company standards and guidelines
Articulates the guidelines to both internal and outside customers as necessary
Seeks to actively meet the expected standards and guidelines in all phases of their work product
Uses appropriate judgment in applying guidelines to achieve the desired outcome
Obtains information and necessary facts to create an electronic claim file. Accurate and timely data entry after confirming coverage under the applicable policy. Refers to designated manager for assignment and follows up.
Serves as first point of contact when members, administrators, agents or brokers contact TDC to report a claim file. Utilize phone software during designated work time. As applicable, transfer to appropriate contact and follow-up to obtain required information.
Acts as primary contact for member service within their assigned region to provide best imaginable service.
Generates all necessary letters for file opening, closing and in support of their assigned claim specialist(s).
Orders death certificates, autopsy reports, statute checks and other public records.
Obtains from necessary parties, signed authorizations and orders medical records.
Organizes medical records for the claims file and prepares records for expert review.
Follows-up on closed files for receipt of dismissal and settlement documents.
Performs various processing duties, such as updating computerized claims records, sending facsimiles/emails, telephone support, and servicing the insured throughout the life of the claims file.
Completes State Reports and other forms.
Receives and follow up on all NPDB coding requests.
Acts as large account point person for reporting allocated and unallocated claims
Coordinate meetings and correspondence upon request.
Processes manual payments as needed.
Prepares accurate settlement check requests and ensures file has Medicare designation
Provides processing assistance for requests from other departments.
Manages unallocated files including assignment of defense counsel and monitoring for timely closure.
Reviews and approves legal invoices on assigned files.
Manages allocated files with reserves below $30,000, which do not require field investigation. Varies by regional office.
Performs other duties as assigned.

Benefits

medical, family and bereavement leave
same-sex domestic partner benefits
short- and long-term disability programs
employee assistance program
Health, dental, and vision insurance
Health and dependent care tax-free spending accounts with a company match
401(k) and Roth IRA with company match, as well as catch-up plans for both
Paid vacation, sick days, and personal days each calendar year (with vacation increases based on length of service)
12 paid holidays each calendar year
Life and travel insurance
Tax-free commuter benefits
In-person and online learning opportunities
Cross-function career opportunities
Business casual work environment
Time off to volunteer
Matching donations to qualifying nonprofit organizations
Company-sponsored participation at non-profit events