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Direct Claims Jobs in Colorado (NOW HIRING)

TriOptus LLC

Director of Claims

Denver, CO · On-site

Oversee staff and direct workflow in order to ensure claims are adjudicated within proper timeframes and payment of claims is executed in an efficient and timely manner. * Ensure claims are paid ...

Ccfs

Risk Claims Manager

Denver, CO · Remote

$85K - $95K/yr

Risk Claims Manager Department: Compliance Job Status: Exempt Compensation ... Direct Reports: Yes COMPANY OVERVIEW CrossCountry Freight Solutions (CCFS) is an exceptional ...

USAA

Sr. Injury Claims Adjuster

Colorado Springs, CO · On-site +1

$63K - $121K/yr

Prioritizes and manages assigned claims workload to keep members and other involved parties ... Directors. The above description reflects the details considered necessary to describe the ...

USAA

Sr. Injury Claims Adjuster

Colorado Springs, CO · On-site +1

$63K - $121K/yr

Prioritizes and manages assigned claims workload to keep members and other involved parties ... Directors. The above description reflects the details considered necessary to describe the ...

USAA

Sr. Injury Claims Adjuster

Colorado Springs, CO · On-site +1

$63K - $121K/yr

Prioritizes and manages assigned claims workload to keep members and other involved parties ... Directors. The above description reflects the details considered necessary to describe the ...

USAA

Sr. Injury Claims Adjuster

Colorado Springs, CO · On-site +1

$63K - $121K/yr

Prioritizes and manages assigned claims workload to keep members and other involved parties ... Directors. The above description reflects the details considered necessary to describe the ...

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Direct Claims information

What is a direct claim?

Direct claims refer to insurance claims that are filed directly by the policyholder with their own insurance company, rather than going through a third party or the at-fault party's insurer. This process is common in situations like auto accidents, where the policyholder seeks compensation for damages or losses under their own policy. Direct claims help streamline the process, reduce delays, and ensure the policyholder receives prompt assistance and settlements. They are often associated with 'first-party' insurance coverage, such as collision, comprehensive, or health insurance claims.

Can you work remotely in direct claims jobs?

Many direct claims jobs offer remote work options, especially for roles involving claims processing, customer service, or administrative tasks. Employers may require familiarity with claims management software and good communication skills, and remote positions often involve standard office hours and secure internet connections.

Do I need a degree to be a direct claims specialist?

A degree is not typically required to become a direct claims specialist, but relevant experience, knowledge of insurance policies, and strong communication skills are important. Many employers provide on-the-job training and may prefer candidates with a high school diploma or equivalent. Certifications in insurance or claims processing can enhance job prospects.

What are some common challenges faced by professionals in direct claims roles, and how can they effectively manage these challenges?

Professionals in Direct Claims often face the challenge of balancing a high volume of claims with the need for thorough investigation and timely resolution. Managing customer expectations and handling sensitive situations, such as denied claims or complex cases, can also be demanding. Effective communication, strong organizational skills, and staying updated on policy guidelines are crucial for success. Building collaborative relationships with adjusters, underwriters, and other departments helps ensure accurate and efficient claims processing.

What are the key skills and qualifications needed to thrive as a direct claims specialist?

To thrive as a Direct Claims Specialist, you need a solid understanding of insurance policies, claims processes, and relevant legal regulations, often supported by a degree in business, finance, or a related field. Familiarity with claims management software, customer relationship management (CRM) systems, and sometimes industry certifications like AIC or CPCU is typical. Exceptional attention to detail, problem-solving abilities, and strong communication skills set top performers apart in this role. These skills and qualifications ensure claims are processed accurately and efficiently, leading to customer satisfaction and minimized risk for the insurer.

What is the difference between Direct Claims vs Claims Adjuster?

AspectDirect ClaimsClaims Adjuster
CredentialsInsurance license, knowledge of policiesInsurance license, sometimes certifications like AIC or CPCU
Work EnvironmentCustomer service, office or remoteFieldwork, office, or remote
Employer & IndustryInsurance companies, agenciesInsurance companies, third-party administrators
Search & Comparison IntentUnderstanding direct claims handlingEvaluating claims adjustment roles

Direct Claims professionals primarily handle claims directly from policyholders, focusing on processing and resolving claims within the insurance company. Claims Adjusters evaluate, investigate, and settle claims, often working in the field or remotely. Both roles require insurance licensing, but Claims Adjusters may have additional certifications. While their work overlaps in claims processing, Direct Claims roles are more customer-facing, whereas Claims Adjusters focus on assessment and negotiation.

What are popular job titles related to Direct Claims jobs in Colorado? For Direct Claims jobs in Colorado, the most frequently searched job titles are:
What job categories do people searching Direct Claims jobs in Colorado look for? The top searched job categories for Direct Claims jobs in Colorado are:
What cities in Colorado are hiring for Direct Claims jobs? Cities in Colorado with the most Direct Claims job openings:
Direct Claims jobs near you

Director of Claims

TriOptus LLC

Denver, CO • On-site

Full-time

Re-posted 7 days ago

Job description

Director of Claims Management
Denver, Colorado (Hybrid)
Full-time/Permanent + Benefits
Responsibilities
  • Under the supervision of the VP of Operational Accounting, the Director, Claims is responsible for ensuring the delivery of timely and efficient claims service through the daily supervision of staff. This position provides technical guidance to staff regarding investigations, adjustments, complex claims, and review and implementation of workflow to individuals based on job type.

Essential Functions and Work Responsibilities
Functional Category: Claim Management
Estimated Percent of time Spent - 80%
  • Maintain a working knowledge of all regulatory and compliance guidelines that affect the scope of the department
  • Responsible for the management and oversight of departmental functions such as claims adjudications, appeals, correspondence, claims adjustments, and claims support.
  • Establish measures and processes by which to collect, monitor, evaluate, and report on key performance indicators
  • Oversee staff and direct workflow in order to ensure claims are adjudicated within proper timeframes and payment of claims is executed in an efficient and timely manner.
  • Ensure claims are paid correctly and timely by performing verification of contracts and utilizing claims software.
  • Ensures appeals are correctly paid and recorded in claims software.
  • Communicate and update management regarding issues affecting the claims department including software, refunds, timeframes, processes, etc.
  • Assist with the evaluation and implementation of claims software including the management of software related issues.
  • Research and manage services procured through third party vendors such as claims auditing.
  • Prepare both recurring and ad hoc reports for management and other stakeholders requiring information regarding claims expenses, utilization or any other claims issues.
  • Attend regular meetings and conferences with regulatory agencies and PACE associations to ensure client is compliant and following best practices.
  • Act as claims representative on committees and project teams for purposes of planning and collaborating on company process improvements and expansion efforts.
  • Work closely with operations and finance to partner on referral processes, IBNR accruals, encounter data submissions, and RAPS reporting.
  • Work with IT team and various vendors to coordinate, manage, and implement change to improve efficiency, data accuracy/governance, and scalability
  • Review, address, and resolve formal grievances directly pertaining to claims.
  • Work as liaison with center directors and center staff to ensure excellent customer service, provider, and utilization management.
  • Perform other special projects as assigned by company management.

Functional Category: Supervision
Estimated Percent of time Spent - 20%
  • Effectively supervises and manages direct reports and provides, by example and leadership, motivation and direction to employees of the organization.
  • Carries out supervisory responsibilities in accordance with the organization's policies and applicable state and federal employment laws.
  • Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; recognizing and rewarding employees; corrective disciplinary procedures and practices (under direction of supervisor and in partnership with Human Resources), addressing complaints and resolving problems.
  • Ensure annual employee performance reviews are conducted in a timely and effective manner. Evaluates performance of employees for compliance with established policies and objectives of the organization and contributions in attaining objectives.
  • Help set the tone of the department to ensure morale, team work, and the positive employment culture of the organization is maintained.
  • Regularly schedules leadership/management, department, and staff 1:1 meetings to provide leadership, development, and a forum for communication to ensure coordination and collaboration in meeting organizational and individual goals.

Qualifications
  • To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

REQUIRED
Education
  • Bachelor's degree in accounting or a related field from an accredited college/university

Work Experience and Qualifications
  • Minimum of ten years of experience in healthcare claims processing; or equivalent combination of education and experience.
  • Experience with researching and resolving errors that result in refunds and adjustments required.
  • Current experience and strong knowledge of co-pays, deductibles, co-insurance, coordination of benefits, pre-existing conditions, primary and secondary insurance and stop loss.
  • Current experience and knowledge of general accounting, medical terminology, ICD-9, CPT coding, CMS 1500, UB2004 and other claim forms and systems.
  • Strong familiarity and skill with Microsoft Office Suite, Check-writer System and Managed Claim Optimizer (MCO).
  • Strong management skills and a minimum of two years of experience supervising staff.

Other Knowledge Skills and Abilities Required
Computer Skills
  • Must be computer proficient and possess experience with Microsoft Word, Excel, and Outlook.
  • Must be able to quickly learn specific software and new applications.

Mathematical/Financial Skills
  • Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
  • Able to analyse data and statistics and draw reasonable conclusions and compile accurate reports.
  • Experience with P/L and developing and managing budgets

Language Skills
  • Ability to read, analyze and interpret regulations and other documents.
  • Strong interpersonal skills and ability to effectively and tactfully present information to, and communicate with, co-workers, employees, and others.
  • Possess exceptional English written and verbal communication skills, including accurate grammar and business correspondence knowledge.
  • Ability to read and write memos, reports, and correspondence that conform to prescribed style and format.

Reasoning Ability
  • Ability to define problems, collects data, establish facts, and draw valid conclusions.

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