Claims Specialist-WC

Crawford & Company • Hauppauge, NY

122d

About The Position

The position involves administering and resolving non-complex short term claims of low monetary amounts, including medical only claims. The role requires documenting and monitoring open case inventory to ensure proper and timely closing of files. The individual will make decisions on claims within delegated limited authority. A college degree or equivalent education and experience is required, along with knowledge of claims and familiarity with claims terminology gained through industry experience or specialized courses of study, such as the Associate in Claim designation. The candidate must demonstrate a thorough working knowledge of claim processing and claim policies and procedures, as well as an understanding of basic medical terminology and appropriate medical tests for claimed conditions. Effective and diplomatic oral and written communication skills are essential, along with a customer-focused approach to identify and understand customer needs and interact effectively with others. The candidate must secure and maintain the appropriate license(s) as required by the state(s) at the adjuster/supervisory/management level and possess a valid driver's license. Continuing education requirements as outlined by Crawford Educational Services must be completed, and additional courses may be required by jurisdiction for maintenance of the license.

Requirements

• College degree or equivalent education and experience.
• Knowledge of claims and familiarity with claims terminology.
• Demonstrated thorough working knowledge of claim processing and claim policies and procedures.
• Understanding of basic medical terminology and appropriate medical tests for claimed conditions.
• Effective and diplomatic oral and written communication skills.
• Customer-focused approach to identify and understand customer needs.
• Ability to interact effectively with others.
• Must have or secure and maintain the appropriate license(s) as required by the state(s).
• Possess a valid driver's license.
• Complete continuing education requirements as outlined by Crawford Educational Services.

Responsibilities

• Conduct investigations of claims to confirm coverage and determine liability, compensability, and damages.
• Work closely with claimants, witnesses, and members of the medical profession pertinent to the investigation and processing of claims.
• Verify policy coverage for submitted claims and notify the insured of any issues.
• Determine and establish reserve requirements, adjusting reserves as necessary during the processing of the claim.
• Identify wage loss expenses and wage exposures on medical claims.
• Document receipt and contents of medical reports.
• Interact frequently with claimants to understand the nature and extent of injury and medical conditions.
• Review and handle correspondence within authority including material from team members and/or clients.
• Approve payments of medical bills on lost time disability claims within area of payment authority up to $2,500 after compensability has been determined.
• Evaluate medical claims for potential fraud issues, loss control, and recovery in accordance with insurance policy contracts, medical bill coding rules, and state regulations.
• Keep Team Manager informed verbally and in writing of activities and problems within assigned area of responsibility.
• Refer matters beyond limits of authority and expertise to Team Manager for direction.
• Provide input on the completion of status reports, initiate activity checks and/or widow's statement of dependency forms.
• Complete all reporting forms and file documentation.
• Adhere to client and carrier guidelines and prepare written updates for supervisor to review.
• Perform other related duties as required or requested.

What This Job Offers

• Industry: Insurance Carriers and Related Activities
• Education Level: Bachelor's degree