Claim Representative II - Auto

Blue Cross Blue Shield of Michigan•Lansing, MI

13d•Onsite

About The Position

This is the intermediate level of the claims handling career path responsible for managing a caseload of Michigan No-Fault Personal Injury Protection (PIP) claims of moderate to high complexity. The Claim Representative II investigates and administers both litigated and non-litigated PIP claims, exercising independent judgment in coverage analysis, compensability determinations, exposure evaluation, and claim resolution. The position requires thorough knowledge of Michigan No-Fault law, including order of priority investigations, coverage verification, injury causation analysis, and litigation management. The Claim Representative II collaborates regularly with insureds, claimants, healthcare providers, attorneys, and internal business partners to ensure timely, accurate, and compliant claim handling. This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be may be required.

Requirements

Bachelor’s degree in a related field. Relevant combination of education and MACP claim handling experience may be considered, in lieu of degree.
Three years’ experience in handling MCAP claims in an environment which provides the necessary skills, knowledge and abilities, such as experience in reviewing, investigating and closing MACP claims.
Ability and proficiency in the use of computers and company standard software specific to position.
Knowledge of medical and legal terminology related to the work.
Knowledge and handing of Michigan Assigned Claims Plan and Michigan Automobile No Fault and regulations, including jurisdictional laws.
Effective oral and written communication skills.
Effective customer service skills.
Ability to negotiate, build consensus and resolve conflict.
Ability to manage multiple priorities and meet established deadlines.
Attention to detail and analytical skills.
Ability to work independently as well as within a team.
Ability to make independent decisions.
Ability to solve complex problems.

Nice To Haves

Continuous learning, as defined by the Company’s learning philosophy, is required.
Certification or progress toward certification is highly preferred and encouraged.
Experience handling claims in multiple jurisdictions preferred.
Bilingual skills preferred.

Responsibilities

Determines compensability under Michigan Assigned Claims Plan and the Michigan No Fault Act by a thorough investigation of the claim.
Determines causal relationship between the reported injury and the incident to ensure appropriate payment of benefits.
Establishes timely and appropriate reserves based on the profile of the claim within given authority based on anticipated financial exposure.
Documents specifics of claims with potential for subrogation recovery, including amount of potential recovery monies.
Manages medical bills for Michigan No Fault claims directly associated with the claimed injury.
Approves payment based on knowledge of the treatment plan and medical support showing relationship of treatment to the injury.
Concludes and closes files following resolution of claims to meet internal and client directives performance standards while complying with state legislation to avoid penalties and manage expenses.
Negotiates settlements with attorneys or injured parties within given authority at the earliest possible point to bring cases to final disposition.
Works closely with manager on complex files or files above settlement/reserve authority.
Manages outside vendors to ensure cost containment efforts.
Establishes and maintains effective working relationships with all internal and external customers.
Stays abreast of changes in Michigan No-Fault and Michigan Assigned Claims Plan statutes and, case law and rehabilitation efforts/advancements in order to accurately interpret and apply relevant laws.
Administers complex claims and catastrophic exposures within authority, including claims from dedicated large accounts.
Exercises independent judgment to settle cases prior to mediation or litigation.
Actively participates in agent/client relationship management.
Assists in mentoring team members.