About this role
Description
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Manages, investigates and resolves medical claims assigned to them. Communicates with customers, attorneys and medical providers by phone and other channels, both initiating and responding to inquiries. Evaluates coverage, eligibility, medical necessity and causality, and recognizes and resolves problems of moderate scope and complexity.
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Training is a critical component to your success and that success starts with reliable attendance. Attendance and active engagement during training is mandatory
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Hiring for our Mid-Atlantic team that handles MD, DE, KY, PA & MN
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Responsibilities:
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Manages, evaluates and resolves claims. Evaluates coverage, eligibility, medical necessity, causality and resolves claims within prescribed authority.
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Communicates with policyholders, agents, witnesses, and claimants in order to gather information regarding claims and refers tasks to auxiliary resources as necessary. Responds to various written and telephone inquiries including status reports.
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Reviews medical records and bills to verify claimed treatment is causally related to the accident and is reasonable and necessary given facts of the claim.
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Ensures adequacy of reserves and settlement authority.
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Confirms or denies coverage and advises policyholders, agents and claimants as to proper course of action.
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Makes effective use of loss management techniques (IMEs, Nurse Review, and Bill Review).
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Negotiates settlements with attorneys, claimants, and medical providers.
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Arranges for expert inspections involving third party or potential fraud actions as needed.
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Updates files and provides comprehensive reports as required.
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Identifies and recommends referral of potentially fraudulent claims to the Special Investigation Unit.
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Recognizes continuous improvement opportunities and develops
Qualifications
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Strong written and oral communications skills required. Good interpersonal, analytical, decision making and negotiation skills required.
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Customer service experience preferred.
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Knowledge of legal liability, general insurance policy coverage and the ability to review and understand medical records to determine causality and medical necessity.
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The capabilities, skills and knowledge required is normally acquired through a Bachelor’s degree or equivalent experience and 6-12 months of directly related experience.
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Ability to obtain proper licensing as required.
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Only open to US based employees.
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Employees may apply for a new role after completing 12 months of employment in their current position.
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Employees should review all role requirements and apply only for positions for which they are eligible. Hiring processes may vary by country, including differences in procedures, requirements, and timelines. For country-specific details, please consult your local recruiting / HR team.