Medical Only Claims Specialist II - ARS

Emergent Holdings•Lansing, MI

9h•Onsite

About The Position

The Medical Only Claims Specialist II is an experienced level claims role. The incumbent is expected to perform at a high level with minimum supervision. Primarily responsible for the investigation and management of workers’ compensation claims. Conducts one point contact on the managed claims, determines compensability of claims, manages the medical treatment program, and confirms the claimant’s disability will not exceed waiting period timelines. This includes calling and discussing potential claim activity and work-related injuries with policyholders, and claimants, providers, attorneys, agents, and state agencies, when necessary.

Requirements

1 years’ experience as a MOCS I with demonstrated competency in multiple jurisdictions.
Minimum of three (3) years insurance experience.
Two (2) years of demonstrated technical knowledge (i.e. applying relevant workers compensation laws, regulations, guidelines, and/or policies that would impact claims and/or underwriting outcomes) including one (1) year managing workers' compensation claims required.
Relevant customer service experience exchanging information and answering and resolving inquiries over the phone required.
General knowledge of claims operations specifically claims processes.
Ability to work effectively in a multifunctional business unit.
Excellent verbal and written communication skills.
Ability to use diplomacy, discretion, and appropriate judgment when responding to inquiries from staff and external customers as well as anticipating needs of the department.
Ability to effectively exchange information clearly and concisely, and present ideas, report facts and other information and respond to questions as appropriate.
Basic knowledge of Workers Compensation in one or more states including jurisdictional laws.
Basic knowledge of statutory standards in multiple states.
Ability to apply relevant workers’ compensation laws and regulations, including jurisdictional laws.
Ability to negotiate, build consensus, and resolve conflict.
Excellent organizational skills and ability to prioritize work.
Ability to manage multiple priorities and meet established deadlines.
Ability to perform mathematical calculations.
Excellent analytical and problem-solving skills.
Ability to use reference manuals.
Knowledge of medical terminology.
Knowledge of legal terminology.
Ability to comprehend various claims issues, address them or refer them for appropriate decision-making.
Ability to analyze details of workers compensation claims and as a result able to make competent, independent decisions within authority.
Ability to work with minimal direction.
Ability to travel to locations outside of the office.
Ability to proofread documents for accuracy of spelling, grammar, punctuation, and format.
Demonstrated ability to use diplomacy, discretion, and appropriate judgment when responding to inquiries from staff and external customers as well as anticipating needs of the department.
Demonstrated ability to effectively exchange information clearly and concisely, and present ideas, report facts and other information and respond to questions as appropriate.
Knowledge of Workers Compensation in one or more states including jurisdictional laws.
Knowledge of statutory standards in multiple states.
Demonstrated ability to negotiate, build consensus, and resolve conflict.
Demonstrated ability to manage multiple priorities and meet established deadlines.
Demonstrated ability to comprehend various claims issues, address them or refer them for appropriate decision-making.
Demonstrated ability to analyze details of workers compensation claims and as a result able to make competent, independent decisions within authority.
Demonstrated ability to work with minimal direction.

Nice To Haves

Associate degree in insurance and/or related field with progress towards or completion of Insurance Institute of America (IIA) or other insurance related designation(s). Combinations of education and experience may be considered in lieu of a degree.
Progress towards or completion of the Insurance Institute of America (IIA) or other insurance related designation(s) preferred

Responsibilities

Investigates workers’ compensation claims including a mandatory contact to the employer within the required time frame with additional contacts to the employee or provider, as necessary.
Inform medical providers of billing address and billing requirements.
Documents claim file.
Verifies workers’ compensation coverage (statutory and policy) of employers and injured employees.
Determines, documents, and manages the on-going medical treatment program including directing care, confirming jurisdictional specific panels, and approving provider requests.
Remains abreast of new caselaw decisions affecting claim and medical management.
Monitors the work status of the injured workers, and notifies manager when the potential for lost time exposure exists so that the claim can be transferred.
Evaluates medical reports and correspondence for appropriate action/documentation.
Supports the customer service work and processes for the multi-functional claims team; Communicates and collaborates with team members to ensure the appropriate and timely handling of claims in other states.
Required to handle multiple jurisdictions.
Establishes timely and appropriate reserves based on the profile of the claim within given authority based on anticipated financial exposure. Documents in the claim file the basis for reserve calculations.
Determines causal relationship between the reported injury and the incident to ensure appropriate payment of benefits.
Documents specifics of claims with the potential for subrogation recovery.
Assists Subro representative with investigation.
Engages ISU to obtain police reports.
Approves, edits, and denies 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 performance standards while complying with state legislation to avoid penalties and manage expenses.
Coordinates with outside vendors to ensure cost containment efforts, when necessary.
Establishes and maintains effective working relationships with all internal and external customers. Assists with determining appropriate response to regulatory inquiries.
Coordinates all efforts with proprietary technology, including causation investigations, and future models.
Determines appropriate response to regulatory inquiries and completes statutory filings, including EDI data completion.
Composes correspondence and various reports in the administration of workers compensation claims; sets appropriate diaries.
Reads, routes and keys incoming mail, runs reports and answers/responds to incoming phone calls on both direct and ACD line, faxes, and emails. This may include completing work for peers during absences to provide uninterrupted service to customers.
Schedules independent medical evaluations and provides synopsis and outlines all questions to the IME physician. Upon receipt of results, communicates to all affected parties, facilitates future treatment, or may result in formal denials being filed.
Assigns ISU to complete causation investigation.
Stays abreast of changes in workers’ compensation statutes, case law and rehabilitation efforts/advancements to accurately interpret and apply relevant laws.
Manages prescription requests, medical treatment, and validates work status for injured employees.
Validates return to work for the injured employee and monitors work status on medical only claims with a keep at work focus.
May serve as an adjuster to the dedicated account representative.
Supports the team, as required, by acting as a back up to the MOCS.
Approves, edits and denies medical bills for non-indemnity and indemnity claims directly associated with the claimed injury based on knowledge of the treatment plan and medical support showing relationship of treatment to the injury.
May conduct employee/employer interviews to assist in the return-to-work process.
Supports the account management process appropriately for the team’s block of business.
Trains and mentors other team members.
Mentors fellow team members and assists in their development as a MOCS.
Works with minimum supervision.
May attend agent and/or policyholder visits.
Monitors death benefit and maintenance claims for items such as age reduction, coordination of benefits, Stozicki, Second Injury Fund, dependent drops and supplemental payments.
Works closely with manager on complex files or files above reserve authority.