Medical Only Claims Specialist, Workers' Compensation

Encova Insurance

1d•$49,225 - $78,759•Remote

About The Position

The Medical Only Claims Specialist, Workers’ Compensation manages a high frequency desk, which includes primarily medical only claims. The Medical Only Claims Specialist is responsible for the investigation, evaluation, and determination of compensability for work-related injury and disease claims following established guidelines to determine benefit eligibility. The position’s objective is to provide superior service in a cost-effective manner to achieve best possible outcomes as well as proactively collaborate across the enterprise to ensure alignment of objectives and foster continuous improvement.

Requirements

Bachelor’s Degree from an accredited college or university is preferred.
One year of experience in the field of insurance, customer service, claims investigation, legal, rehabilitation, or medical claims processing required. Workers’ compensation claims experience and licensure preferred.
Must pass the claims adjuster license exam(s) as assigned within 6 months of being hired.
Ability to use logic and sound reasoning to identify alternative solutions for problem-solving.
Strong written and verbal communication skills.
Strong analytical skills.
Ability to multitask and manage time effectively and productively.
Work effectively independently as well as in a team environment.
Develop and maintain strong, effective internal and external relationships.
Work effectively in a paperless environment.
Skilled in the use of laptops, claims management systems, and other typical business-related programs such as Microsoft Office suite.

Nice To Haves

Preference may be shown to candidates with multiple state claims management experience.
Workers’ compensation claims experience and licensure preferred.
Ideal candidates will have Workers' Compensation claims handling experience in Pennsylvania.
Maryland, Delaware, DC or New Jersey workers compensation claims handling would be a plus.

Responsibilities

Gathers relevant facts by performing three-point contacts with involved parties and completing a thorough claim investigation prior to issuing a compensability determination.
Decides the outcome of claims using sound judgment and applying established policy, procedures, regulations, and guidelines.
Evaluates and establishes an action plan to manage benefits associated with primarily medical only and occupational disease claims to their most cost-effective conclusion.
Determines eligibility of benefits once medical treatment plans have been secured and processed within the designated authority levels.
Actively identifies and develops the investigation of and pursuit of subrogation recoveries when possible.
Utilize proactive reserving behaviors to ensure adequate case reserves which reflect the probable ultimate outcome based on the current known circumstances throughout the life of the claim.
Consults with lost time claims specialists and/or complex claims specialists, director or Claims Product and Operations staff, as needed.
Analyzes reports from external resources such as physicians, attorneys, and/or vocational rehabilitation experts to evaluate and adjust claim strategies as needed.
Evaluates and negotiates claim settlements utilizing human relation skills and technical knowledge to achieve the best possible outcome.
Consults with assigned claim director if the loss becomes more complex or presents increasing financial exposure.
Effectively and independently uses available resources to prioritize, organize, and complete work in a timely manner to meet jurisdictional requirements, timeframes, and internal metrics.
Follows established claims best practices related to medical management, litigation, fraud/abuse and recovery.
Presents claims and participates in discussion at team staffing.
Works collaboratively with the injured worker, employer, outside counsel, and health and rehabilitation professionals to manage the claims costs and promote quality medical care.
Along with the claim director, regional vice president and other claims staff, participates in claim reviews, onboardings, etc. for our policyholders and agents.
Proactively collaborate with our policyholders to ensure alignment of objectives and foster continuous improvement.