Claims Director (Stop Loss)

Department: Legal, Audit & Compliance

Employment Type: Permanent - Full Time

Location: Home United States

Compensation: $65,000 - $75,000 / year

Description

Our StoryImagine being part of a team that’s not just shaping the future but actively driving it. At Davies North America, we’re at the forefront of innovation and excellence, blending cutting-edge technology with top-tier professional services. As a vital part of the global Davies Group, we help businesses navigate risk, optimize operations, and spearhead transformation in the insurance and regulated sectors.
What's in Store

We are on the lookout for a Claims Director (Stop Loss) to join our team. As the Claims Director you will be adjudicating accident and health medical claims and pharmacy benefits for traditional medical, employer stop loss specific and aggregate excess, HMO Re or Provider Excess of Loss, and Medical Excess of Loss and Reinsurance claims.

To be successful in this role, you must have excellent communication skills, superb organization and attention to detail skills and possess the ability to multitask in a fast-paced environment. 

Key Responsibilities

• Maintain communication with clients and intermediaries on a regular basis for assigned accounts
• Comfortable working solo or collaborating with clients, intermediaries, and peers
• Highly skilled and experienced adjudicating accident and health medical claims and pharmacy benefits for traditional medical, employer stop loss specific and aggregate excess, HMO Re or Provider Excess of Loss, and Medical Excess of Loss and Reinsurance claims
• Audit and review of managed care and provider excess provider agreements and health plan/TPA contracts and adjudicating claims accordingly
• Audit and review of employer stop loss specific and aggregate excess claims
• Knowledgeable of CMS regulations, Medicare fee schedules, Medicare programs, Medicaid fee schedules & Medicaid programs for state level agencies
• Maintaining communication with clients and intermediaries on a regular basis for assigned accounts.
• Perform peer editing and training
• Occasional travel to perform claim support during off-site audits, projects, and assignments with the A&H audit team
• Support company values of We are Dynamic, We are Innovative, We are Connected, and We Succeed Together
• Perform other duties as assigned

This is a full-time, home-based position that will require occasional travel.

Skills, knowledge & expertise

• A minimum of 5+ years medical claims experience
• Ability to work independently and collaborate on assignments in a fast-paced environment
• Knowledge of first dollar medical and pharmacy claims, claim processing platforms, CMS regulations and medical terminology and coding
• Ability to occasionally travel to perform claim support during off-site audits and assignments
• Well versed in self-insured and managed care concepts
• Excellent written, verbal, and analytical skills and attention to detail is required
• Strong Microsoft Office/Word/Excel skills required

Benefits

BenefitsAt Davies North America, we are dedicated to supporting the well-being and future of our qualifying employees. Our comprehensive benefits package includes:

• Medical, dental, and vision plans to ensure your health and that of your family.
• A 401k plan with employer matching to help you build a secure financial future.
• Our time-off policies, including Discretionary Time Off for exempt employees and Paid Time Off (PTO) package for non-exempt employees, reflect our commitment to promoting a healthy work environment.
• Paid holidays.
• Life insurance and both short-term and long-term disability plans, providing essential financial protection for you and your loved ones.

 Diversity and InclusionDavies is dedicated to fostering a diverse and inclusive workplace that embraces a wide range of perspectives and experiences. We believe that diversity of thought is essential for innovation and creativity, and we actively promote an environment where all voices are valued and heard.