Medical Claims Specialist

Role Overview

• Successfully completes the Medical Claims Training Program.
• In classroom training, is attentive, takes notes, asks appropriate questions, participates successfully in exercises, and demonstrates mastery of the subject material.
• In the Medical Claims Unit, asks appropriate questions, exhibits continuous improvement under the guidance of the supervisor, and demonstrates mastery of fundamental adjusting knowledge, skills, and strategy.
• Learns medical subjects including anatomy, physiology, terminology, pharmacology, causation, nature of the injury, and diagnostic and treatment methodology.
• Learns legal subjects including relevant statutes and regulations.
• Learns to effectively and efficiently use the computer systems employed in the management of claims.
• Learns skills such as investigative and persuasive communication, decision-making, and documentation.
• For clients who are provided with a dedicated Claims Medical Specialist, establishes and maintains a sound working and communication relationship with the client’s contact personnel.
• Determines coverage for new claims.
• Conducts and directs the investigation of new claims to determine compensability and severity and to gather all other relevant information.
• Calculates appropriate reserves and ensures that reserves are adjusted as needed.
• Ensures that benefits are provided in accordance with the law and that the claim as a whole is managed in accordance with all legal requirements including the issuance of appropriate notices and filings.
• Manages each claim to an appropriate and successful resolution.
• Ensures that work is performed in accordance with Company procedures, standards, training, and supervisory direction.
• Fosters a positive and close working relationship with other Company staff, including the Call Center, Medical Management teams, Client Services, and indemnity Adjusting staff.

Requirements

• EDUCATION: Minimum of High School Diploma or equivalent certificate required.
• EXPERIENCE: Administrative experience in the areas of law, medicine, insurance/workers compensation, telephonic communication, or negotiation is useful but not necessary.
• REASONING ABILITY: Able to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Able to deal with problems involving several concrete variables in standardized situations.
• COMPUTER SKILLS: Able to effectively use Microsoft Office Suite applications. Able to quickly master proprietary and vended software applications.

Benefits

• Manageable Caseloads
• Work-Life Balance
• Work From Home Program (up to 2 days per week)
• Free On-Site Fitness Facility
• Free On-Site Garage Parking