Accident and Health Senior Claims Specialist (Provider XS/ESL)

About the role

This position provides senior claims handling expertise across all product lines within the Accident and Health division, including claims adjudicated both in-house and by Third-Party Administrators (TPAs) and MGUs. Primary products include, but are not limited to: Managed Care, HMO, Medical Excess, Provider Excess, and Employer Stop Loss. Additional Specialty products include Leisure Travel, Excess Accident, Pet, Firefighter Line of Duty, Limited Medical Benefits, and Voluntary Benefits (Accident Medical, Critical Illness, Vision, Dental, and Short-Term Disability).

Responsibilities

• Strong understanding of HMO, excess medical, stop-loss, and high-severity claims
• Knowledge of medical cost containment strategies and provider/network dynamics
• Understanding and handling of Specialty A&H products
• Conduct annual and desk audits of MGUs and TPAs, including preparation and presentation of audit findings and reports
• Aid with due diligence reviews of prospective TPAs and support onboarding processes
• Maintain oversight procedures for MGUs and TPAs
• Support the development and maintenance of guidelines for processing specialty A&H claims
• Review claims exceeding MGU and TPA authority thresholds, including second-level appeals
• Coordinate responses to complaints, attorneys, carrier reviews, and benefit clarifications
• Provide oversight of Provider Excess structures and HMO/Managed Care provider reimbursement
• Gather, analyze, and interpret monthly reporting data to identify trends and implement corrective action plans as needed
• Partner with underwriting, actuarial, and product development teams to communicate claim trends and insights
• Produce and review reports for management
• Lead special projects with multi-month planning horizons

Requirements

• Prior experience with MGU oversight, including Stop Loss, Provider Excess, and Managed Care claims
• Strong Accident & Health claims management experience, including medical claims and cost containment
• Experience auditing and reviewing Third-Party Administrators
• Exposure to evaluation and reserving experience
• Bachelor’s degree or equivalent industry experience
• Insurance designation preferred
• 4-6 years of experience with stop-loss, HMO managed care, excess provider, captive programs including A&H products

Qualifications

• Highly proficient in Microsoft Office Suite (Outlook, Word, Excel, PowerPoint)
• Strong analytical skills, including ability to interpret data; Power BI experience a plus
• Excellent written, negotiation, and communication skills
• Proven ability to work collaboratively, manage deadlines, and operate effectively in a dynamic environment
• Comfortable interacting across all levels of the organization and with external business partners

Skills

• Comprehensive knowledge of Accident and Health claims management
• Ability to handle complex claims involving various products
• Proficiency in auditing and reviewing Third-Party Administrators
• Strong analytical and problem-solving skills
• Effective communication and collaboration abilities

Benefits

• Base salary range: $104K – $138K (based on experience and location)
• Competitive incentive compensation tied to corporate and individual performance
• Comprehensive benefits package including:
• Medical, dental, and vision plans
• Health and wellness programs
• Retail plans
• Tuition reimbursement
• Paid time off and additional benefits

Pay

• Base salary range: $104K – $138K (based on experience and location)

Schedule

• Preferred candidates will be able to commute to an AXIS office three days per week
• Travel several times per year within the U.S. and Canada for on-site TPA audits