Medical Claims Examiner

Penske•Cumru Township, PA

About The Position

The Medical Only/Subrogation Claims Examiner provides dedicated operational oversight of Medical Only workers’ compensation claims and subrogation activity administered by Penske’s Third-Party Administrator. The role supports the Workers’ Compensation team by monitoring claim activity, identifying escalation concerns, improving consistency in claim handling, tracking recovery opportunities, and coordinating follow-up with Gallagher Bassett, internal stakeholders, and legal counsel as needed. The position is intended to help reduce claim leakage, improve escalation timing, strengthen documentation and follow-up, support return-to-work monitoring, and maximize recovery opportunities. The posting cites approximately 144 subrogation opportunities annually, average annual incurred exposure of approximately $7.75 million, current open subrogation exposure of approximately $22.7 million, a historical average recovery rate of 18.66%, and estimated current recovery potential of approximately $4.2 million.

Requirements

1–3 years of experience.
Intermediate working knowledge of workers’ compensation claim-handling principles, Medical Only claim management, escalation indicators, return-to-work monitoring, subrogation and recovery processes, claim documentation review, workers’ compensation terminology, medical documentation, and claim-handling expectations.
Intermediate proficiency with Access, Risk/FACS, Oracle, Microsoft Excel, Microsoft Teams, Microsoft Outlook, and claims management/reporting tools.
Ability to identify trends, concerns, escalation indicators, recovery opportunities, operational risks, red flags, inconsistencies, and statute-of-limitations concerns.
Ability to independently review claim information, ask appropriate follow-up questions, evaluate varied claim scenarios, recommend practical solutions, and escalate matters appropriately.
Strong written and verbal communication skills and ability to communicate with field management, Human Resources, legal counsel, medical providers, TPA representatives, Examiners, management, and senior leadership.
Strong collaboration, follow-up, organization, documentation accuracy, prioritization, and attention to detail.
Regular, predictable, full attendance is an essential function of the job.
Willingness to travel as necessary, work the required schedule, and work at the specific required location.
Completion of a Penske employment application and submission to a background investigation, including past employment, education, and criminal history, and drug screening are required.
A bachelor’s degree in Business Administration, Risk Management, Insurance, Healthcare Administration, Paralegal Studies, or a related field is preferred; equivalent work experience is required if the applicant has no degree.

Nice To Haves

Experience in workers’ compensation, insurance claims, Medical Only claim handling or oversight, subrogation coordination, lien review, recovery processes, TPA claim administration, or a self-insured workers’ compensation program; equivalent relevant experience may be considered in lieu of degree requirements.
Workers’ compensation, insurance claims, risk management, paralegal, subrogation, or related claims certifications/designations.

Responsibilities

Monitor and oversee the TPA’s handling of Medical Only workers’ compensation claims, review activity for escalation triggers, and monitor return-to-work status and modified-duty duration.
Communicate with field management, Human Resources, and internal stakeholders about work-status concerns and claim progression.
Review claim documentation for consistency and completeness; identify red flags and escalate concerns to Workers’ Compensation Examiners or management.
Monitor claims for potential subrogation opportunities and review subrogation referrals and recovery evaluations completed by Gallagher Bassett.
Track statute-of-limitations exposure and recovery activity; coordinate with Gallagher Bassett subrogation representatives on investigations, documentation, and recovery progression.
Review recovery recommendations, provide observations to Workers’ Compensation Examiners and management, and coordinate with legal counsel and internal stakeholders as necessary.
Maintain accurate documentation and tracking tools; prepare status reports and management updates; assist with reporting standards and templates.
Audit claim-handling quality and monitor compliance with departmental procedures and claim-handling expectations.
Participate in claim reviews, operational meetings, and strategy discussions; collaborate on escalated matters; assist with training and communication initiatives; and support departmental transitions and operational projects.
Perform other projects and tasks as assigned.