What are the responsibilities and job description for the Claims Director position at Davies Group?
Our Story
Imagine 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 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 stop loss experience, excellent communication skills, superb organization and attention to detail skills and possess the ability to multitask in a fast-paced environment.
Key responsibilities include :
- 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.
Your Expertise, Skills, and Abilities
Benefits
At Davies North America, we are dedicated to supporting the well-being and future of our qualifying employees. Our comprehensive benefits package includes :
Diversity and Inclusion
Davies 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.
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