Davies · 1 week ago
Claims Director
United States
Full-time
Remote
Senior Level, Lead/Staff
$80K/yr - $90K/yr
10+ years expDavies Group is a specialized professional services and technology firm that partners with leading organizations in regulated industries. The Claims Director will lead the Excess Claims Management division, focusing on quantifying and verifying excess claims in the Accident & Health insurance sector while ensuring high standards of service and compliance with regulations.
Commercial InsuranceFinancial ServicesInsuranceInsurTech
No H1B
Responsibilities
Highly skilled and experienced at adjudication of 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, risk sharing documents and healthplan/TPA contracts
Utilize in-house Claims Adjudication System (CAS), build Profiles and run data submissions for import & export of files
Audit and review of employer stop loss specific and aggregate excess claims utilizing Summary Plan Descriptions, policies and related supporting documents
Knowledgeable of CMS regulations, Medicare fee schedules, Medicare programs, Medicaid fee schedules & Medicaid programs for state level agencies
Knowledge of internal claim systems and external claims systems utilized to perform claims review
Ensuring assigned accounts have sufficient backup claim support; assume manager’s responsibilities during any absence
Leading and structuring communications with clients, intermediaries and colleagues on a regular basis for assigned accounts
Conduct peer editing and training
Maintain Quality Review performance files
Initiate regular communication with manager in respect of training needs for self or peers
Occasional travel to perform claim support during off-site audits, projects, and assignments with the A&H audit team
Qualification
Required
10+ years of medical claims or stop loss industry experience
Highly skilled and experienced at adjudication of 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, risk sharing documents and healthplan/TPA contracts
Utilize in-house Claims Adjudication System (CAS), build Profiles and run data submissions for import & export of files
Audit and review of employer stop loss specific and aggregate excess claims utilizing Summary Plan Descriptions, policies and related supporting documents
Knowledgeable of CMS regulations, Medicare fee schedules, Medicare programs, Medicaid fee schedules & Medicaid programs for state level agencies
Knowledge of internal claim systems and external claims systems utilized to perform claims review
Ensuring assigned accounts have sufficient backup claim support; assume manager's responsibilities during any absence
Leading and structuring communications with clients, intermediaries and colleagues on a regular basis for assigned accounts
Conduct peer editing and training
Maintain Quality Review performance files
Initiate regular communication with manager in respect of training needs for self or peers
Occasional travel to perform claim support during off-site audits, projects, and assignments with the A&H audit team
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
Well versed in self-insured and managed care concepts
Intermediate level MS Word and MS Excel
Strong communication skills, written and verbal
Excellent analytical skills
Effective interpersonal skills and willingness to adjust interactions based on targeted audience
Exceptionally well organized and focused with a high level of attention to detail
Collaborative communication with key stakeholders at all levels, internally and externally
Driven to work independently as well as capable if working with colleagues
Discretion when handling confidential information
Must have US work rights
Must reside in the U.S
Benefits
Medical PPO or HMO Plan (BCBS)
Dental Plan (MetLife)
Vision Plan (EyeMed)
Life Insurance Plan
Short Term Disability Plan
Long Term Disability Plan
401k Employer Matching
Paid Time Off
Paid Holidays
Company
Davies
We are a specialist professional services and technology firm, working in partnership with leading insurance, highly regulated and global businesses.
5001-10000 employees
Funding
Current Stage
Late StageTotal Funding
$369.18MKey Investors
Blackstone Credit
2025-05-22Debt Financing· $369.18M
2021-03-16Acquired
2020-01-21Private Equity
Leadership Team
Dan Saulter
Group CEO
Recent News
FF News | Fintech Finance
2025-09-19
The Fintech Times
2025-03-18
Company data provided by crunchbase