Clinical Pharmacist – Prior Authorization

by twochickswithasidehustle | Jul 17, 2026 | Uncategorized

remote typeRemotelocationsWork At Home-Texastime typeFull timeposted onPosted 3 Days Agotime left to applyEnd Date: July 19, 2026 (1 day left to apply)job requisition idR0969160

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Ready to take your Clinical Pharmacist skills to the next level with a Fortune 6 company? Check out this outstanding opportunity for a Clinical Pharmacist with CVS Health.

This position is for a Clinical Pharmacist working in the Prior Authorization team.

– Collaborates with the technicians and prior authorization team members to process referrals, including answering clinical questions and collecting appropriate clinical/medical data needed to perform clinical assessments and reviews as per the health plan/employer-agreed criteria within the designated service level agreements.
– Evaluate and review all prior authorization requests and render coverage determinations based on clinical criteria and plan design. Includes verifying insurance coverage and eligibility, interpreting clinical guideline criteria, consulting physicians and other healthcare providers, and appropriately utilizing clinical knowledge and resources while complying with department protocols.
– One of the crucial responsibilities is to guarantee that the decisions regarding cases are conveyed promptly and efficiently to all the healthcare providers, health plans/employers, patients, and other healthcare professionals following agreed-upon approval & denial management processes.
– Performs and handles inbound and outbound phone calls with technicians, prior authorization team members, physicians, healthcare providers, and/or patients to facilitate prior authorization requests, answer inquiries, and/or resolve escalations.
– Establishes and maintains communication among CVS Caremark, health plan, and employer group staff.
– Maintains professional and technical knowledge of drug and disease states for the Specialty and Non-Specialty Pharmacy programs administered within the Commercial Prior Authorization and Case Review Unit (CRU) line of business.
– Performs other related projects and duties as assigned, including attending training sessions and development meetings, and providing on-call and after-hours pharmacist availability as needed.
 
This is a remote role open to candidates within the United States.

Required Skills & Other Minimum Required Qualifications:

• Active, unrestricted pharmacist licensure
• Current pharmacist experience within Caremark PA Ops required
• Ability and willingness to work a flexible hourly schedule to include overtime, weekends, and holidays as needed
• Knowledge of Microsoft Office Suite: Excel and Word required; Access, Outlook, PowerPoint, Visio preferable.  Keyboard skills essential.
• Must be able to multitask and utilize multiple system applications simultaneously.
• Must be able to utilize available resources independently and provide high quality work.
• Must demonstrate problem solving ability and attention to detail.
• Ability to adapt and change with workflow and shifting priorities.
• Ability to work effectively in a team environment and provide mentorship to non-clinical staff on the prior authorization team.
• Must possess excellent written, verbal, grammar, and listening communication skills.
• Must be able to effectively communicate with a diverse customer base (internal and external) in a friendly and confident manner.
• Ability to maintain confidentiality of PHI (Protected Healthcare Information).

Education

BS in Pharmacy or Pharm D

Anticipated Weekly Hours40

Time TypeFull time

Pay Range

The typical pay range for this role is:

$50.48 – $84.62

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
 

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Additional details about available benefits are provided during the application process and on Benefits Moments.

We anticipate the application window for this opening will close on: 07/19/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Senior Professional Quality

by twochickswithasidehustle | Jul 17, 2026 | Uncategorized

Date:  Jun 25, 2026

Location:  

Any city, OK, US, 99999

Req ID:  36754

Work Mode:  Virtual (Exception only)

Great companies need great teams to propel their operations. Join the group that solves business challenges and enhances the way we work and grow. Working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values your contributions and puts a premium on work flexibility, learning, and career development. 

Summary

As a Senior Professional Quality at Gainwell, you serve as a Quality Assurance (QA) subject matter expert (SME) for the Customer Experience (CX) organization, leveraging deep healthcare operations and quality expertise to provide hands‑on QA support across new and existing programs, projects, and scopes of work. As an individual contributor, drives execution of QA activities while supporting the achievement of account and operational deliverables. Provides peer coaching, mentoring, and escalation support, and partners closely with Accounts, Regions, and cross‑functional stakeholders. Through collaboration, influence, and disciplined execution, quality standards are consistently applied, and goals and objectives are achieved.

Here are the details on this position.

Your role in our mission

• Support, and as needed perform quality evaluations across all channels (call center and back-office work), completing required and targeted assessments, testing, audits, and retesting (complex and non‑complex) to validate controls, corrective actions, and sustained compliance.
• Analyze objective and subjective evidence to assess quality, identify root causes, support training and process improvement feedback loops and improve performance; serve as escalation support to QA team members and assist leader with unresolved or high‑risk issues.
• Provide hands-on support for DDIs, GTGs, and projects as assigned.
• Serve as peer coach, mentor, and provide work guidance to QA and Operations team members.
• Serve as a subject matter expert and escalation resource for complex quality issues; drive consistency through calibration and standardized evaluation practices (engagement and facilitation).
• Partner with leaders and staff to maintain and enhance DLPs, SOPs, and support documentation and collateral to support consistent execution of work.
• Collect, analyze, and trend quality and defect metrics; deliver concise written and verbal reporting with actionable insights and recommended solutions for leaders and stakeholders.
• Partner cross‑functionally with Operations, Compliance, Legal, and business leaders to support QA initiatives, projects, and external audits while mitigating regulatory and operational risk.

What we’re looking for

• 4+ years Quality Assurance subject matter experiences (including not limited to evaluating, leading calibrations, conducting audit routines, assessment studies and trend analysis, quality methodology and practices); and a Bachelor’s degree or equivalent experience.
• Deep healthcare operations expertise, preferably in a Supervisory role / capacity in Medicaid / Medicare the voice (call center) and non-voice (back-office) area(s).
• Strong written and verbal communication skills; hands-on change management planning and execution experience; with demonstrated attention to detail and adaptability to respond to changing business needs.
• Excellent organizational and time management skills; skilled at working independently and as part of a team with a proven track record of driving quality improvements.
• Proficient with Microsoft Office suite and hardware and software applications to manage contact center and back-office operations (including Verint and CXOne).

What you should expect in this role

• Fully remote position. 
• Office Hours – 8a-5p central time
• Opportunity to travel through your work up to 25% of the time.
• This posting is intended for pipelining. This is a developing position therefore the job description is subject to change.
• #LI-HC1

The pay range for this position is $58,900 – $84,100 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.

We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.

Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. Gainwell Technologies defines “wages” and “wage rates” to include “all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.

Compliance Improvement Manager

by twochickswithasidehustle | Jul 16, 2026 | Uncategorized

HealthPlanOne’s mission is to help people find the right health insurance at the right price, so they live healthier lives. We are committed to making the shopping process simpler. Our mission has never been more important than it is today.The Compliance Improvement Manager is responsible for strengthening compliance adherence, optimizing call center operations, and driving compliance-focused performance initiatives across the organization. This role collaborates with key stakeholders to improve compliance processes, streamline operational workflows, and enhance agent and leader development through targeted training, monitoring, and performance support. The Compliance Improvement Manager works closely with compliance leadership, sales teams, and carrier partners to ensure regulatory requirements are met while supporting efficiency and service quality within the Medicare call center environment.

Supervisory Responsibilities: Directly manages a team of Compliance Analysts and oversees their daily work and development.

Duties/Responsibilities:

• Support compliance and performance strategy by implementing CMS and carrier aligned initiatives and guiding process improvements that enhance regulatory adherence and operational efficiency.

• Monitor compliance trends and analytics by reviewing KPIs, audit results, coaching data, CTM activity, and retention patterns to identify risks and improvement opportunities.

• Lead compliance coaching and retraining for agents and leaders while overseeing a team that supports preparation and monitoring and will eventually assist in coaching and remediation activities.

• Partner with internal teams on training, scripting, and call-flow alignment to ensure compliance accuracy and consistent application of regulatory requirements across materials and workflows.

• Enhance operational and compliance processes by collaborating with cross-functional teams to streamline workflows, reduce inefficiencies, and strengthen adherence to CMS and carrier guidelines.

• Provide audit, remediation, and reporting support by reviewing audit and performance trends, developing corrective strategies, and participating in carrier compliance reviews with concise, data-driven insights.

• Independently manage all carrier-facing compliance communication by representing the Compliance department during carrier meetings, reviews, and external partnership discussions.

• Perform other related duties as assigned to support compliance initiatives and organizational effectiveness.

Required Skills/Abilities:

• Bachelor’s degree or equivalent
• 6 years’ experience in Medicare Advantage, Prescription Drug Plan and Regulatory Compliance in healthcare or insurance.
• Strong knowledge of CMS regulations, Medicare compliance standards, and carrier requirements.
• Familiarity with audit & monitoring tools for compliance tracking and performance improvement.
• Experience in risk management, compliance reporting, and process optimization.
• The ability to collaborate with training teams and leadership to ensure compliance and performance initiatives are effectively communicated and adopted.
• Strong oral and written communication skills for supporting training development and compliance discussions.
• Ability to analyze compliance and performance trends, identify areas of improvement, and assist in implementing improvement programs.
• Experience in trend analysis, remediation support, and compliance monitoring.

Preferred Skills/Abilities:

• Proven strength in compliance coaching, regulatory interpretation, and improving call center adherence through analytics and cross-department collaboration. Ability to build strong carrier relationships while supporting internal teams through training and process improvement.

Physical Requirements:

• Must be able to remain in a stationary position (e.g., sitting or standing) for extended periods of time, typically in a cubicle environment (constant noise, fluorescent overhead lighting)
• Frequent use of a computer, dual monitors, keyboard, mouse, and other standard office equipment such as a telephone, copier, and printer.
• Must be able to communicate effectively, including exchanging information in person, in writing, by telephone, email or video conferencing.
• Visual and auditory acuity required to perform job duties effectively, including reading, writing, and interpreting information on screens or in print.
• Hand dexterity, fine motor skills needed to operate a keyboard and mouse efficiently
• Reach with hands and arms occasionally

For Hybrid Roles:

• Must be able to commute to an office setting as required, which may include walking short distances and navigating an office environment.
• Occasionally moves about the office to access files, office machinery, and meet with others.

Equal Employment Opportunity (EEO) is a fundamental principle at HealthPlanOne, where employment is based upon personal capabilities and qualifications. HealthPlanOne does not discriminate because of actual or perceived sex, sexual orientation or preference, gender identity, gender, transgender, race, color, religion, national origin, creed, citizenship status, ancestry, age, marital status, pregnancy, childbirth or related medical conditions, medical conditions including genetic characteristics, mental or physical disability, military and veteran status, or any other protected characteristic as established by law. HealthPlanOne requires the necessary drug testing and background checks as part of our pre-employment practices. If you need assistance or an accommodation due to a disability, please contact us to request accommodation at [email protected]

Grants and Contracts Manager (Remote)

by twochickswithasidehustle | Jul 16, 2026 | Uncategorized

School of Medicine

Established in 1930, Duke University School of Medicine is the youngest of the nation’s top medical schools. Ranked sixth among medical schools in the nation, the School takes pride in being an inclusive community of outstanding learners, investigators, clinicians, and staff where interdisciplinary collaboration is embraced and great ideas accelerate translation of fundamental scientific discoveries to improve human health locally and around the globe. Composed of more than 2,500 faculty physicians and researchers, more than 1,300 students, and more than 6,000 staff, the Duke University School of Medicine along with the Duke University School of Nursing, Duke University Health System and the Private Diagnostic Clinic (PDC) comprise Duke Health. a world-class academic medical center. The Health System encompasses Duke University Hospital, Duke Regional Hospital, Duke Raleigh Hospital, Duke Primary Care, Duke Home and Hospice, Duke Health and Wellness, and multiple affiliations.

Join a collaborative research administration team where you will independently manage complex grants and contracts portfolio and play a key role in supporting the successful execution of high‑impact research!

Be You.

This position will be located within the School of Medicine Shared Research Administration Resource (RASR) Group and will play an active role in working with specifically identified departments to manage their portfolio of grants and contracts.

Coordinate and/or perform pre-award and/or post-award activities for a unit (school, department, division, institute, or center) that has a large, complex, and/or diverse portfolio of grants and contracts.

Pre- award activities include broad duties in preparation and submission of grant and contract proposals. Ensures all applications meet agency and university guidelines and published time tables and deadlines. Ensures proposals are entered and routed in a timely manner for further review.

Post-award activities include detailed reconciliation of assigned project budget, including determination of allocability and allowability of charges; preparing and analyzing budget reports, and developing budget projections; adjusting and correcting assigned project budgets to meet project goals and federal requirements, providing assistance and oversight to effort management of specified project portfolio.

This position is responsible for a specified highly complex grants and contracts portfolio using discretion and independent judgment to make decisions that impact the compliance and successful completion of grant and contract objectives. This position is expected to manage a mid- sized unit (school, department, division, institute, or center) with a well-defined grant and contract portfolio.

This position functions as a manager and/or facilitator of large projects, such as grants and contracts that span across multiple disciplines and faculty.

Work Arrangement – This position has the option to be 100% remote. Candidates must reside in one of the approved states for remote work, which can be viewed here: https://remotework.duke.edu/policy/outside-nc/

DEPARTMENTAL PREFEERENCES

Experience in an academic institution; Pre-award and post-award management of federal grants.

Certified Research Administrator preferred.

MINIMUM QUALIFICATIONS

Education/Training – Work requires communications, analytical and organizational skills generally acquired through completion of a bachelor’s degree program. Research or grants education and/or certification is preferred.

• Successful completion of the Research Administration Academy (RAA) and Advanced Grants Management is required. Employees hired into this classification without the expected credentials will work closely with their manager to schedule and successfully complete all training (12 months to complete RAA and an additional 6 months to complete AGM). Successful completion of all expected training will be an annual performance goal until complete.
• Upon completion of expected training, the employee must maintain Research Administration Academy (RAA) certification and Advanced Grants Management (AGM) certification by completing continuing education requirements.
• Successful completion of Financial Services Introduction to R3, Introduction to Duke GL, Introduction to Accounting, Sponsored Research Reporting, Research Administration at Duke (on-line), Basic Compliance (on-line) within first six months of hire is required.

Experience – Work generally requires three (3) years of relevant grants and contracts experience.

Be Bold.

Skills    

• Ability and desire to complete Advanced Grants Management training (in most circumstances an employee will be expected to hold a RAA certification before moving into this classification).
• Demonstrated skills in analyzing data and formulating conclusions.
• Ability to learn changing technologies related to grants and contracts management.
• Full command of grants and contracts systems; requires solid working knowledge of MS Office Suite (Word, Access, Excel, Power Point).
• Ability to communicate both verbally and in writing with all levels of the organization.
• Ability to manage and prioritize multiple projects/tasks simultaneously.
• Ability to create verbal and written reports.
• Understand and apply knowledge of national compliance issues to circumstances at Duke University.
• Understanding of asset management for funded projects as applied to Duke University policies and practices. Able to direct others n asset management and to review, troubleshoot and approve asset management.

Work Performed

Pre-award (30%)

• Coordinate work for the group ensuring proper distribution of assignments and adequate manning, space and facilities for subsequent performance of duties.
• Manage large projects that span across multiple disciplines and faculty.
• Serves as the point person for team members on grants and contracts issues as well as questions related to university guidelines.
• Provide guidance to the PI on the requirements of the IRB, IACUC, COI, IBC, and research related regulations including proposal submission and award set-up. Consult with department compliance liaison as necessary.
• Review proposal submissions for compliance with export controls.
• Manage the subcontract process with ORA/ORS and collaborating organizations.
• Develop budgets and budget justifications which include proofing the budget for inconsistencies, ensuring accuracy and consistency between budgets and budget justification which includes sub-recipient information secured from sub-agreements.
• Advise the PI on administrative requirements in preparing proposal submissions.
• Prepare, coordinate and review certain proposal elements (biosketches and facilities & resources) for consistency, accuracy, and completeness.
• Monitor compliance with agency and University regulations regarding submission; verify all financial information to include application of the appropriate overhead rate for the project.
• Review sponsored projects through SPS to ORA/ORS to ensure compliance with University procedures and institutional signatures.
• Ensure understanding of the current fiscal performance of studies and identify areas of concern that need resolution. Advise PI on budget adjustments and revisions necessary to meet the sponsor requirements.
• Monitor proposal status and advise PI on requirements and deadlines associated with research protection protocols.

Post-award (40%)

• Develop project management plan for review by the PI or senior level grants administrator.
• Make cost-sharing adjustments to reflect appropriate labor distribution or related cost-sharing obligations.
• Manage budget, reporting and compliance timelines through the lifecycle of the grant or contract; communicate new WBSEs to appropriate department personnel.
• Establish sub-recipient requirements and provide on-going sub- recipient monitoring. Coordinate issuance of sub-agreements with ORA/ORS.
• Review and evaluate the Site Based Research charge assignment grids based on the schedule of events and protocol for the study.
• Establish and implement project management plans for complex projects.
• Reconcile monthly budget reports, implement adjustments and inform PI and/or supervisor of corrections/adjustments that have been made.
• Prepare budget projects and analysis to assist PI in financial grant management
• Identify the need for cost transfers from budget reconciliation; submit/approve the cost transfers.
• As requirements change, prepare and submit requests for re- budgeting/modifying the funded project budget. Reconcile and close all sub-recipient budgets and obtain all sponsor-required reports.
• Monitor compliance with agency and University regulations regarding reporting.
• Maintain financial records per the institutional documents’ retention guidelines.
• Ensure process (SOP) is in place within the unit for proper handling of sponsor checks for deposit and recording in the appropriate fund codes. This must be handled in accordance with the institutions check handling process.
• Monitor and determine appropriate charging of patient care expenses to the study fund codes.
• Interpret departmental policies and procedures, making decisions on specific operating problems and issuing instructions on behalf of unit.
• Manage overdrafts in line with unit procedures and institution guidance.
• Ensure proper recording of revenue associated with all studies; apply revenue management standards.
• Closeout all funded projects consistent with university process and timelines.
• Perform overall grants monitoring using tools available to monitor compliance with Duke policies.

Management (30%)

• Submits reports to the Divisional Administrator/Business Manager when requested
• Recommend various personnel actions including, but not limited to, hiring, training performance appraisal, promotions, transfers and vacation schedules.
• Supervisory Responsibilities: Supervise other grants and contracts positions and support personnel.
• Understand and apply basic concepts of Export controls as these relate to proposal submission and award management
• Understand and be able to apply federal rules to contract negotiations and management
• Understand and be able to apply budget management to contracts
• Understand and be able to assist others in understanding contract terminology
• Understand and be able to comply with Duke University requirements for managing Federal contracts
• Understand and be able to assist others in understanding the basic Federal and Duke University rules, regulations and requirements of IRB, IACUC, COI, IBC and Misconduct Science.
• Able to clearly communicate when interacting with faculty to inform of obligations in meeting these requirements and when faculty is not complying with policies.
• Able to escalate issues to higher levels when unable to get cooperation from others
• Able to establish and maintain systems to ensure timely compliance with RCR requirements
• Understand and be able to operationalize the development and maintenance of internal controls within a Duke University unit.
• Able to understand and apply basic internal control concepts to daily management of Federal awards.
• Understand and be able to translate concepts to actual practice at Duke University.
• Understand and apply the basic concepts of clinical research in the Duke University compliance environment
• Understand and be able to apply federal and university rules to management of effort allocation for individuals compensated whole or in part from federal awards.
• Understand and be able to manage complex effort scenarios resulting from multiple appointment types (VA, University).
• Understand the management requirements of broadly represented aspects of Federal financial research compliance and to develop strategies for meeting compliance expectations within a dedicated unit and/or assigned portfolio.

The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those specifically presented in this description.

Choose Duke.

Apply today to take ownership of a complex grants and contracts portfolio and make a meaningful impact on the success of high‑impact research initiatives!

Anticipated Pay Range: Duke University provides an annual base salary range for this position as USD $67,732.00 to USD $116,282.00. Duke University considers factors such as (but not limited to) scope and responsibilities of the position; candidate’s work experience, education/training, and key skills; internal peer equity; as well as market and organizational considerations when extending an offer.

Your total compensation goesbeyond the dollars on your paycheck. Duke provides comprehensive and competitive medical and dental care programs, generous retirement benefits, and a wide array of family-friendly and cultural programs to eligible team members.

Learn more at: https://hr.duke.edu/benefits/

Equal Opportunity Employer: Duke is an Equal Opportunity Employer committed to providing employment opportunity without regard to an individual’s age, color, disability, gender,gender expression, gender identity, genetic information, national origin, race, religion, (including pregnancy and pregnancy related conditions), sexual orientation, or military status.

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it isessential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Essential Physical Job Functions:

Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and reasonable accommodation(s) can be requested with Duke Access and Accommodations Services (email: [email protected]; phone: 919-668-1267).

Claims Specialist, Workers Compensation – Remote

by twochickswithasidehustle | Jul 16, 2026 | Uncategorized

Crum & Forster (C&F) provides market leading property & casualty, accident & health, specialty and standard commercial lines insurance solutions. A true underwriting company, we have a 200-year history of helping our customers manage risk with laser-focused expertise, integrity and discipline. Our people are empowered to make decisions and   problem-solve with you smartly and swiftly. Our annual gross written premium is 6.2 billion. C&F enjoys a financial strength rating of “A+” (Superior) by AM Best.

Our most valuable asset is our people. We have 3000 employees, and locations throughout the United States and India. With our employee-first focus, the Company is consistently recognized as a great place to work, earning multiple workplace and wellness awards, including the Great Place to Work® Award, Fortune 100 Best Companies to Work For, Fortune Best Workplaces for Parents, Fortune Best Workplaces for Millennials, and many others.

C&F is part of Fairfax Financial Holdings. For more information about C&F, please visit our website: www.cfins.com

Job Description

Examines claims data and conducts investigations into routine and moderately complex claims to determine coverage, compensability, subrogation and benefits under moderate supervisory direction. Adjusts and manages claims within the limit of assigned authority.

What you will do for C&F:

• Must be well versed in California Compensation statute claims.
• Receives lost time and complex medical only assignments. Verifies and determines applicability of coverage. Initiates 24-hour contact with employer, employee and 48-hour contact with attending physician.
• Handles catastrophic claims with supervisory oversight.
• Conducts telephone investigations as required by company claims handling manual and procedures.
• Evaluates and adjusts claims within the limits of authority.
• Consults with Claim Manager on those claims where assistance and consultation is needed.
• Makes assignments to nurse case management when indicated, monitoring their billing and performance.
• Sets reserves for anticipated exposure up to authority limits.
• Completes mandatory Reserve Worksheets. Establishes reserves requiring complex analysis with lifetime pharmacy and cost inflation.
• Coordinates return to work (RTW) and sets target dates.
• Maintain diaries on maximum three (3) month intervals.
• Documents files in the claims system.
• Reviews medical bills for causal relationship, medical bill charges for appropriateness and approves payments.
• Adheres to special account handling (SHI) instructions.
• Attends account meetings by telephone and in-person.
• Manages litigation on the files.

What you bring to C&F:

• College degree, B.A. or equivalent experience.
• 3+ years experience handling workers compensation claims.
• Strong organizational skills.
• Good time management skills.
• Foreign language communications a plus.
• Excellent verbal and written communication skills are essential.
• Strong aptitude and knowledge of Microsoft Office programs and the ability to quickly learn new programs.
• Will abide by departmental policies and procedures, including authority levels, to comply with C&F’s risk management controls.

What C&F will bring to you

• Competitive compensation package
• Generous 401K employer match
• Employee Stock Purchase plan with employer matching
• Generous Paid Time Off
• Excellent benefits that go beyond health, dental & vision. Our programs are focused on your whole family’s wellness, including your physical, mental and financial wellbeing
• A core C&F tenet is owning your career development, so we provide a wealth of ways for you to keep learning, including tuition reimbursement, industry-related certifications and professional training to keep you progressing on your chosen path
• A dynamic, ambitious, fun and exciting work environment
• We believe you do well by doing good and want to encourage a spirit of social and community responsibility, matching donation program, volunteer opportunities, and an employee-driven corporate giving program that lets you participate and support your community

At C&F you will BELONG

If you require special accommodations, please let us know. We value inclusivity and diversity. We are committed to equal employment opportunity and welcome everyone regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender identity, or Veteran status. If you require special accommodations, please let us know

 For California Residents Only:  Information collected and processed as part of your career profile and any job applications you choose to submit are subject to our privacy notices and policies, visit https://www.cfins.com/onlineprivacypolicy/ca/noticeatcollection/  for more information.

Crum & Forster is committed to ensuring a workplace free from discriminatory pay disparities and complying with applicable pay equity laws.  Salary ranges are available for all positions at this location, taking into account roles with a comparable level of responsibility and impact in the relevant labor market and these salary ranges are regularly reviewed and adjusted in accordance with prevailing market conditions. The annualized base pay for the advertised position, located in the specified area, ranges from a minimum of $55,800.00 to a maximum of $104,900.00. The actual compensation is determined by various factors, including but not limited to the market pay for the jobs at each level, the responsibilities and skills required for each job, and the employee’s contribution (performance) in that role. To be considered within market range, a salary is at or above the minimum of the range. You may also have the opportunity to participate in discretionary equity (stock) based compensation and/or performance-based variable pay programs.