- Investigates assigned claims for coverage, promptly notifying Corporate Claims of any issues, so that MEM's position can be evaluated, and appropriate correspondence issued. Documents every claim with a coverage analysis notepad.
- Investigates assigned claims for compensability and any applicable drug/safety/alcohol penalties, in accordance with the appropriate state statutes. This includes taking verbal, written or recorded statements from key witnesses and securing any and all records to document and support the decision made.
- Recognizes and acts upon opportunities when a Face-to-Face visit would provide maximum value to investigate, establish rapport or minimize litigation potential. Engage Field Service Manager to assist when needed.
- Remains alert to opportunities when surveillance may be an effective method for either managing disability or supporting Special Investigation needs. Secures approval for this process, evaluates an appropriate vendor and manages the cost/benefit balance while using this tool.
- Identifies subrogation, investigates and documents third party liability in order to maximize potential recovery dollars.
- Oversees the medical aspects of the files to ensure quality care in a cost-effective manner. This includes working with network providers, referring to Utilization Management, engaging Nurse Case Management when appropriate and securing special opinions as needed (such as Specialists, Independent Medical Evaluations, Second Opinions, Functional Capacity Evaluations, Medical Director input, permanent restrictions, and lifetime medical needs). Reviews and processes medical bills in a timely manner.
- Ensures system data integrity by entering and maintaining accurate information in required fields.
- Documents files with all relevant facts and actions taken, action plan, necessary reports, investigative notes, and other data as may be required by the state Workers' Compensation Law, Federal Longshore and Harbor Workers' Compensation Act, the State Insurance Department and MEM guidelines.
- Effectively manages disability via the Return-to-Work Program, which includes securing job descriptions and Policyholder education about the benefits of providing light duty. Ensures accuracy of disability payments by securing wage statements and correctly calculating rates, which may include securing and analyzing tax information. Ensures benefit payments are timely and in accordance with statutory requirements so that there is no exposure to penalties or interest.
- Establishes and maintains claim reserves, which in the aggregate are sufficient to discharge ultimate corporate liability. This requires timely responsiveness to changing claim circumstances, with avoidance of stair-stepping or significant adverse development. File documentation should be sufficient to explain the rationale for reserve changes. Secure approval for any reserves beyond stated authority. Completes Serious Claim Notices according to guidelines.
- Obtains medical disability ratings in accordance with statutory requirements. Evaluates a reasonable settlement range for claim resolution and negotiates settlements (either directly with the Injured Worker or, if represented, with their attorney) within approved authority levels.
- Recognizes appropriate opportunities for structured settlements and employs the necessary resources to develop and negotiate this type of settlement.
- Directs attorneys in preparing assigned claims for defense and manages legal throughout claim to final resolution/settlement. Collaborates with counsel to determine legal plan of action, which may include depositions, medical examinations and vocational evaluations. Ensures MEM litigation guidelines are followed throughout the process and in review/approval of legal bills submitted.
- Recognizes claims with Medicare exposure and works with defense counsel to protect Medicare's interests. Obtain Medicare Set-Aside Trusts from approved vendors and send claims to Centers for Medicare Services for approval, when appropriate. Keeps abreast of Medicare changes.
- Identifies and investigates potential fraud and works with the Special Investigation Unit investigator to provide necessary documentation that may support a referral to the state. When required, provide legal testimony in support of cases that are being prosecuted.
- Provides requested updates to Management on high profile or high dollar claims.
- Prepare and present claims for Corporate Plan of Action meetings and Account Claim Reviews as requested.
- Performs other duties as may be dictated by office/department/corporate circumstances.
- Pay Type Salary
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Claims Representative - Ballwin, United States - Missouri Employers Mutual Insurance
3 weeks ago
Description
Are you driven to keep people safe? That's what we do every day at Missouri Employers Mutual.
We've created a casual, values-driven work culture that's making a positive impact on the way people live and work. This is a place where you can grow with confidence - because that's what safety and success really mean to us.
SUMMARY:
Under the general direction of the Claims Manager or senior level Claims Reps: investigates, evaluates, negotiates, and settles assigned medium/high exposure, with some highly complex claims, following sound claims handling techniques and in accordance with company claims philosophy, statutory requirements and quality assurance standards. Must be able to work independently, with minimal supervision and within assigned authority.
Claims Investigations
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education:
Bachelor's degree in Business Administration, Insurance, or closely related field preferred
Experience:
3 or more years' experience handling Worker's Compensation Claims required
Designations/Certifications:
AIC is preferred but not required.
AIM preferred but not required.
Our home office is located in vibrant Columbia, Missouri - #6 in Livability's 2019 Best Places to Live.
Other details
