Sr. Medical Management Specialist

Erie Insurance • Town of Henrietta, NY

3d • Onsite

About The Position

Responsible for handling complex medical management claims and litigation portion of first party claims exercising discretion and independent judgement in handling of work. This position is based out of our New York Branch Claims Office in Rochester.

Requirements

• High School Diploma or GED and five years of previous Medical Management claims handling experience, or
• Bachelor’s Degree and three years of previous Medical Management claims handling experience required.
• Strong working knowledge of applicable state laws required.
• Strong working knowledge of human anatomy and medical terminology required.
• Expertise in state no-fault laws and knowledge of civil law required.
• Working knowledge of medical bill repricing system required.
• Appropriate license as required by state.

Nice To Haves

• Knowledge of multiple medical management jurisdictions preferred.
• Successful completion of AIC courses preferred.

Responsibilities

• Handles first party medical benefit claims, including but not limited to: complex coverage, litigation, complex fatalities complex wage loss claims and claims involving suspected fraud.and/or misrepresentation. Evaluates and makes independent decisions regarding coverage. Conducts investigations, determines total value of claims, sets, and maintains adequate reserves, and manages cases.
• Handles litigation portion of first party claims, settles within authority as appropriate and works with defense counsel when defending suit on litigation strategy.
• Investigates, evaluates, and resolves complex coverage questions for multiple jurisdictions, including claims outside ERIE’s footprint in compliance with the appropriate applicable state laws.
• Investigates, evaluates and resolves claims with suspected fraud/misrepresentation, including working with ISS, Examiner, Underwriting and counsel as needed,
• Prepares related correspondence and reports, obtains medical and employment related records, calculates wage loss claims per applicable state laws and brings claims to conclusion.
• Establishes immediate contact with Policyholders, Claimants, Agents, and counsel as necessary.
• Reviews claim files on a regular basis and takes necessary follow-up and/or closing action.
• Evaluates, processes, and takes appropriate action on claim-related bills and medical, rehabilitation and special investigative reports. Determines claims to be paid, compromised, or contested.
• Attends industry-related training programs to stay current on legal developments and ensure compliance with applicable laws and regulations impacting the operation of the department.
• Assists or acts on the behalf of supervisor when required, including handling of insurance department complaints.
• When appropriate identifies subrogation situations and initiates appropriate action.
• Develops expertise in legal and medical terminology and procedures.
• Assists in training branch office personnel in related matters.
• Assigns, monitors, and controls activities of vendors in a cost-effective manner

Benefits

• Premier health, prescription, dental, and vision benefits for you and your dependents. Coverage begins your first day of work.
• Low contributions to medical and prescription premiums. We currently pay up to 97% of employees’ monthly premium costs.
• Pension. We are one of only 13 Fortune 500 companies to offer a traditional pension plan. Full-time employees are vested after five years of service.
• 401(k) with up to 4% contribution match. The 401(k) is offered in addition to the pension.
• Paid time off. Paid vacation, personal days, sick days, bereavement days and parental leave.
• Career development. Including a tuition reimbursement program for higher education and industry designations.
• Additional benefits that include company-paid basic life insurance; short-and long-term disability insurance; orthodontic coverage for children and adults; adoption assistance; fertility and infertility coverage; well-being programs; paid volunteer hours for service to your community; and dollar-for-dollar matching of your charitable gifts each year.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED