Senior Claims Specialist - Accident & Health Claims

About the position AXIS Capital is seeking a Senior Claims Specialist to join our North America Accident & Health Claims team, reporting directly to the Head of Accident and Health Claims. This position is pivotal in providing senior claims handling expertise across all product lines within the Accident and Health division. The role encompasses claims adjudicated both in-house and by Third-Party Administrators (TPAs). The primary products managed by this position include Limited Medical Benefits such as Hospital Indemnity, Accident Medical, Critical Illness, Vision, Dental, and Short-term Disability, as well as Accidental Death and Accident Medical coverages, disability claims, business travel, leisure travel, and Pet Insurance. The Senior Claims Specialist will be responsible for auditing Third-Party Administrators, which includes preparing and presenting audit reports and findings. This role may involve being part of a Claims Audit Team or traveling to assess claims. The specialist will conduct monthly desk audits of key Third-Party Administrators and assist in the due diligence audit of potential TPAs, including their subsequent onboarding. Monitoring oversight procedures for TPAs and maintaining guidelines for processing specialty accident and health insurance claims will also be key responsibilities. The position requires reviewing claims that exceed the TPA threshold, managing second-level appeals, coordinating responses to complaints and attorneys, and clarifying benefits with carriers. In addition, the Senior Claims Specialist will process larger, more complex claims that are not administered by TPAs, assist in developing cost containment protocols, and obtain, collate, and review data from monthly TPA reporting packages to identify trends and seek corrective action when necessary. Communication with underwriting, actuarial, and product development teams regarding claim trends is essential, as is producing and reviewing reports for management. The role may also involve leading special projects with a planning horizon of several months or more, along with other duties as assigned.

Responsibilities

• Auditing of Third-Party Administrators, including preparation and presenting audit reports and findings.

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• Conducting monthly desk audits of key Third-Party Administrators.

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• Assisting in the due diligence audit of potential Third-Party Administrators and the subsequent onboarding of the TPA.

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• Monitoring oversight procedures for Third-Party Administrators.

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• Assisting in the maintenance of guidelines for processing specialty accident and health insurance claims.

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• Reviewing claims exceeding Third-Party Administrator threshold, second level appeals, and coordinating responses to complaints and attorneys.

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• Processing larger, more complex claims that are not administered by Third-Party Administrators.

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• Assisting in the development of cost containment protocols.

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• Obtaining, collating, and reviewing data from monthly TPA reporting packages for trends and seeking out corrective action plans when required.

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• Communicating with underwriting, actuarial, and product development regarding claim trends.

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• Producing and reviewing reports for management.

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• Leading special projects where planning time horizon is several months or more.

Requirements

• Prior special accident and health insurance claim management experience required, including substantial experience with medical claims and cost containment.

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• Prior experience auditing and reviewing Third-Party Administrators.

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• Knowledge of ERISA and state claim handling requirements.

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• Exposure evaluation and reserving skills.

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• Bachelor's degree or equivalent industry experience required.

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• Insurance designation preferred.

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• Three to five years of A&H claim handling experience.

Nice-to-haves

• Highly proficient in Microsoft Office suite applications (Outlook, Word, Excel, and PowerPoint).

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• Ability to work in a fast-paced, dynamic organization.

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• Ability to analyze data and draw conclusions from data.

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• Excellent writing skills.

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• Excellent negotiation, communication, and interpersonal communication skills.

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• Creative with the ability to 'think outside the box' to effectively solve problems.

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• Demonstrated ability to work in a team, interact well with others, meet deadlines, and successfully perform in a changing work environment.

Benefits

• Medical plans for employees and their families.

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• Health and wellness programs.

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• Retirement plans.

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• Tuition reimbursement.

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• Paid vacation.

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