Claims Specialist-WC

Crawford•Boise, ID

About The Position

Administers and resolves non-complex, short-term claims with low monetary amounts, including medical-only claims. Documents and monitors open case inventory and ensures files are closed properly and promptly. Makes claim decisions within delegated limited authority.

Requirements

College degree or equivalent combination of education and experience.
Knowledge of claims and familiarity with claims terminology gained through industry experience and/or specialized study, such as an Associate in Claims designation.
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, including the ability to identify and understand customer needs and interact effectively with others.
Must have or obtain and maintain appropriate state license(s) at the adjuster, supervisory, or management level, as required.
Valid driver’s license.
Must complete continuing education requirements outlined by Crawford Educational Services; additional courses may be required by the jurisdiction to maintain licensure.

Responsibilities

Investigates claims to confirm coverage and determine liability, compensability, and damages.
Works with claimants, witnesses, medical professionals, and others involved in investigating and processing claims.
Verifies policy coverage for submitted claims and notifies the insured of any issues.
Determines reserve requirements and adjusts reserves as needed during claim processing.
Identifies wage-loss expenses and wage exposures on medical claims.
Documents receipt and contents of medical reports and frequently contacts claimants to understand their injuries and medical conditions.
Reviews and handles correspondence within the role’s authority, including material from team members and clients.
Approves medical bill payments on lost-time disability claims within payment authority, up to $2,500, after compensability has been determined.
Evaluates medical claims for potential fraud, loss control, and recovery in accordance with policy contracts, medical bill coding rules, and state regulations.
Keeps the Team Manager informed verbally and in writing about activities and problems in the assigned area; refers matters beyond authority or expertise to the Team Manager.
With guidance from the Team Manager, provides input on status reports and initiates activity checks and/or widow’s statements of dependency forms.
Completes reporting forms and file documentation.
Adheres to client and carrier guidelines and prepares written updates for supervisor review.
Performs other related duties as required or requested.