Senior Claims Specialist
AXIS (AXIS Capital)•Short Hills, NJ
•$104,000 - $138,000•Hybrid
About The Position
This position provides senior claims handling expertise across all product lines within the Accident and Health division, including claims adjudicated both in-house and by Third-Party Administrators (TPAs) and MGUs. Primary products include, but are not limited to: Managed Care, HMO, Medical Excess, Provider Excess, and Employer Stop Loss. Additional Specialty products include Leisure Travel, Excess Accident, Pet, Firefighter Line of Duty, Limited Medical Benefits, and Voluntary Benefits (Accident Medical, Critical Illness, Vision, Dental, and Short-Term Disability).
Requirements
- Prior experience with MGU oversight, including Stop Loss, Provider Excess, and Managed Care claims
- Strong Accident & Health claims management experience, including medical claims and cost containment
- Experience auditing and reviewing Third-Party Administrators
- Knowledge of ERISA and applicable state claims handling requirements
- Exposure evaluation and reserving experience
- Bachelor’s degree or equivalent industry experience
- 4-6 years of experience with stop-loss, HMO managed care, excess provider, captive programs including A&H products
Nice To Haves
- Insurance designation preferred
- Highly proficient in Microsoft Office Suite (Outlook, Word, Excel, PowerPoint)
- Strong analytical skills, including ability to interpret data; Power BI experience a plus
- Excellent written, negotiation, and communication skills
- Proven ability to work collaboratively, manage deadlines, and operate effectively in a dynamic environment
- Comfortable interacting across all levels of the organization and with external business partners
Responsibilities
- Strong understanding of HMO, excess medical, stop-loss, and high-severity claims
- Knowledge of medical cost containment strategies and provider/network dynamics
- Understanding and handling of Specialty A&H products
- Conduct annual and desk audits of MGUs and TPAs, including preparation and presentation of audit findings and reports
- Assist with due diligence reviews of prospective TPAs and support onboarding processes
- Monitor and enforce oversight procedures for MGUs and TPAs
- Support the development and maintenance of guidelines for processing specialty A&H claims
- Review claims exceeding MGU and TPA authority thresholds, including second-level appeals
- Coordinate responses to complaints, attorneys, carrier reviews, and benefit clarifications
- Provide oversight of Provider Excess structures and HMO/Managed Care provider reimbursement
- Gather, analyze, and interpret monthly reporting data to identify trends and implement corrective action plans as needed
- Partner with underwriting, actuarial, and product development teams to communicate claim trends and insights
- Produce and review reports for management
- Lead special projects with multi-month planning horizons
Benefits
- Medical, dental, and vision plans
- Health and wellness programs
- Retirement plans
- Tuition reimbursement
- Paid time off
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
Upload and Match Resume
What This Job Offers
Job Type
Full-time
Career Level
Senior
