- Review PIP coverages and/or identify coverage issues and investigate and analyze the loss event, the injury, and other relevant information to make a determination as to coverage and course of action.
- Evaluate claims for fraud indicators and potential underwriting issues and process appropriate referrals. Conduct activities in compliance with state and company regulations and guidelines.
- Render final coverage determination within regulatory guidelines: Maintain communication with involved parties during the course of the claim, via written and/or verbal communication, to provide relevant determinations and/or information.
- Maintain communication with involved parties during the course of the claim, via written and/or verbal communication, to provide relevant determinations and/or information. Concisely and accurately document all actions taken throughout the course of the claim.
- Manage all requests for medical treatment, durable medical equipment, PIP Care Paths, medical guidelines and policies, internal and/or external peer reviews, and/or IMEs, when required, communicate determinations to appropriate parties within 3 business days.
- Request necessary Independent Medical Examinations and render determinations for additional treatment or termination benefits.
- Establish adequate medical and non-medical benefits reserves for the life of the claim and adjust reserves, if needed.
- Calculate and issue non-medical benefits (wages, essential services, death benefits).
- Demonstrates knowledge in NJ and in other states and is able to apply regulatory requirements appropriately.
- Understands and applies all process and regulatory knowledge associated with arbitration and subrogation. Effectively utilizes all applications and manages time and responsibilities.
- Excellent verbal and written communication skills, knowledge of Microsoft suite
- Strong interpersonal and customer service skills
- Good organizational, time-management, and data entry skills
- Decision-making and multi-tasking capabilities
- Bachelor's degree preferred
- Able to apply regulatory requirements appropriate by state
- Thorough understanding of all process and regulatory knowledge associated with arbitration and subrogation
- 3-5 years of claims handling experience preferred with out of state (CT, OH, MD, DE) experience strongly preferred
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Medical Claims Adjuster I - Hammonton, United States - NJM Insurance Group
Description
**Medical Claims Adjuster I (PIP Rep I)**
Hammonton, NJ
**NJM Insurance Group**
**
This isn't just insurance. It's NJM.
When you join the NJM family, you'll work with talented people who care about doing the right thing by our policyholders as well as each other. You'll be part of a financially strong and stable company that has flourished on relationships, integrity and service for more than a century. NJM is a special place where you can propel your career, help others and make friends – all at the same time.
NJM is proud to offer our employees continuous learning options, outstanding benefits, access to wellness programs, and a wide range of opportunities to give back to the communities we are privileged to serve.
Our strategic plan for regional expansion is underway. Thanks to both customer and employee dedication, NJM was recently ranked #1 in the nation for auto claims satisfaction by J.D. Power. We were also voted as one of the best places to work in NJ - as noted by Forbes. Come join us
** keywords: position summary,analysis,medical,process,management,compliance,communication,skills,education,experience,knowledge Full Time
**Overview**: Our Hammonton Medical Services Administration team is in search of a PIP Claims Representative. This exciting opportunity is great for someone who is highly organized and enjoys working in a fast-paced environment.
Reporting to the immediate designated PIP Supervisor, the PIP claims representative is responsible and accountable for conducting complete and thorough investigation on assigned claims and medically managing those claims through their life cycle. Entity of type with id: 7159 **Responsibilities**:
For more information:
website:
Legal Disclaimer: NJM is proud to be an equal opportunity employer. We are committed to attracting, retaining and promoting a diverse and inclusive workforce that is fully representative of the diversity that exists in the communities in which we do business.
**Responsibilities**
48_Analyze Created with Sketch. Analysis
Review PIP coverages and/or identify coverage issues and investigate and analyze the loss event, the injury, and other relevant information to make a determination as to ... 48_Medical Created with Sketch. Medical
Request necessary Independent Medical Examinations and render determinations for additional treatment or termination benefits. 48_Individual Contributor Created with Sketch. Process
Understands and applies all process and regulatory knowledge associated with arbitration and subrogation. Concisely and accurately document all actions taken ... 48_Management Created with Sketch. Management
Manage all requests for medical treatment, durable medical equipment, PIP Care Paths, medical guidelines and policies, internal and/or external peer reviews, and/or IMEs, when ... 48_Compliance Created with Sketch. Compliance
Conduct activities in compliance with state and company regulations and guidelines. Establish adequate medical and non-medical benefits reserves for the life of the claim and ... 48_Communication Created with Sketch. Communication
Render final coverage determination within regulatory guidelines: Maintain communication with involved parties during the course of the claim, via written and/or verbal ... **Requirements**
48_Assessment Created with Sketch. Skills
Strong interp
