Medical Only Claims Representative

EMC Insurance Companies • Lowell, MA

2d • Remote

About The Position

At EMC, we’re all about working together to make an impact. As part of our team, you’ll have the opportunity to grow, contribute, and gain experience that matters. We strive to be caring leaders, close partners, and responsive experts—always supporting each other to do our best work. Join us, and let’s improve lives together. This position is eligible to work from home anywhere in the United States Essential Functions: Investigates and evaluates medical only (MO) claims within multiple jurisdictions Reviews the claim notice and policy to verify coverage, deductibles, compensability, and jurisdiction compliance Initiates prompt contact with customers to obtain information and explains the claim process Makes timely contact with insureds, injured employee(s), and witnesses when necessary and documents calls, and activities undertaken within the claims system Confirms return to work status with insureds Confirms appropriate medical care, including use of appropriate cost containment techniques and resources, and takes appropriate actions Sets timely, adequate reserves in compliance with the company reserving philosophy and methodology Provides prompt, detailed responses to agents, insureds, and injured employee on the status of claims Escalates claims to their people leader as appropriate Maintains accurate and timely diaries on all files to handle claims and bring a resolution Completes state reporting as required within jurisdictional guidelines Secures all the necessary reports, claims forms and documents Documents claim handling activity via claim notes, including Medicare (MSP) modules in the claims system Drafts and sends denial letters upon manager approval Issues timely payments within check authority limit Submits referrals to Medical Management and Medical Review Units as appropriate Markets OnCall Nurse (OCN), Return to Work (RTW), Select Preferred Provider (SPP) to insured’s and identifies non-use for corrective measures Prepares risk reports for Underwriting Assists Claims team members with the handling of claims as needed Attends internal and external training and self-study to keep abreast of changes relating to medical treatment, and jurisdictional and statue changes impacting workers compensation benefits Completes ongoing continuing education to remain compliant with jurisdictional licensing requirements.

Requirements

• Associate degree or equivalent relevant experience
• One year of insurance or claims handling experience or related experience
• Attainment of all applicable state licenses within six months of hire
• Basic knowledge of claims adjusting process preferred
• Good knowledge of computers
• Good investigative and problem-solving abilities
• Ability to multi-task and prioritize deadlines
• Strong organizational, written and verbal communication skills
• Strong customer service skills
• Ability to adhere to high standards of professional conduct and code of ethics
• Ability to maintain confidentiality

Nice To Haves

• Bachelor’s degree may be considered in lieu of the experience requirement

Responsibilities

• Investigates and evaluates medical only (MO) claims within multiple jurisdictions
• Reviews the claim notice and policy to verify coverage, deductibles, compensability, and jurisdiction compliance
• Initiates prompt contact with customers to obtain information and explains the claim process
• Makes timely contact with insureds, injured employee(s), and witnesses when necessary and documents calls, and activities undertaken within the claims system
• Confirms return to work status with insureds
• Confirms appropriate medical care, including use of appropriate cost containment techniques and resources, and takes appropriate actions
• Sets timely, adequate reserves in compliance with the company reserving philosophy and methodology
• Provides prompt, detailed responses to agents, insureds, and injured employee on the status of claims
• Escalates claims to their people leader as appropriate
• Maintains accurate and timely diaries on all files to handle claims and bring a resolution
• Completes state reporting as required within jurisdictional guidelines
• Secures all the necessary reports, claims forms and documents
• Documents claim handling activity via claim notes, including Medicare (MSP) modules in the claims system
• Drafts and sends denial letters upon manager approval
• Issues timely payments within check authority limit
• Submits referrals to Medical Management and Medical Review Units as appropriate
• Markets OnCall Nurse (OCN), Return to Work (RTW), Select Preferred Provider (SPP) to insured’s and identifies non-use for corrective measures
• Prepares risk reports for Underwriting
• Assists Claims team members with the handling of claims as needed
• Attends internal and external training and self-study to keep abreast of changes relating to medical treatment, and jurisdictional and statue changes impacting workers compensation benefits
• Completes ongoing continuing education to remain compliant with jurisdictional licensing requirements.

Benefits

• Outstanding benefits with life, medical, dental, vision and prescription drug coverage
• Competitive paid time off plan and a full day of volunteer time off annually
• Financial incentives, including a 401(k) plan match, pension plan, OneEMC bonus plan and recognition and anniversary awards
• Professional development and growth opportunities, including tuition reimbursement
• Wellness initiatives to improve team member well-being and reduce health insurance costs
• Flexibility to dress for your day and opportunities for alternative work arrangements

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree