Claims Director

With a global team of more than 5,000 professionals, Davies Group is a specialized professional services and technology firm working in partnership with leading organizations in highly regulated and global businesses including insurance, financial services, utilities, and regulatory bodies. 

At Davies Group, we help clients manage risk, operate core business processes, and to transform and grow. We deliver operations, consulting and technology solutions across the risk and insurance value chain, including excellence in claims, underwriting, distribution, regulation, customer experience, human capital, transformation and change management.

Davies’ Insurance Services division specializes in consulting, claim and premium auditing and operational review services in the Accident & Health insurance and reinsurance industry.  Our clients include organizations in the insurance and reinsurance industries as well as employers, governmental entities, and other risk assumption areas.  The Accident & Health Audit Solutions subdivision is headquartered in Danvers, MA and has offices throughout the United States.


Davies Insurance Services is looking for a Claims Director for the Excess Claims Management division of Davies north America Insurance Solutions to quantify and verify excess claims specific to HMO Reinsurance, Provider Excess of Loss, Employer Stop Loss and other Reinsurance coverages. The ideal candidate has the appropriate experience and demeanor to independently while receiving direction as needed. This role will be a key part of the team, working within a global professional services and technology firm that prides itself on providing the highest standards of service to its clients and requires someone that aligns with Davies Values: We Are connected, We Are Dynamic, We Are Innovative, We Succeed Together. We can help you achieve lasting success in an energetic and positive environment.

• 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

Experience
• 10+ years of medical claims or stop loss industry experience

Knowledge, Skills, & Abilities
• 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

Essential Requirements
• Must have US work rights
• Must reside in the U.S.

Diversity & Inclusion
Davies is committed to being a diverse and inclusive workplace. We welcome candidates of all genders, gender identity and expression, neurodiversity, sexual orientation, disability, physical appearance, body size, race, age, nationality, and belief (or lack thereof).

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