- Reviews the claim notice and policy to verify coverage, deductibles, compensability, and jurisdiction compliance
- Initiates prompt contact with customers to obtain information and explains the claim process
- Makes timely contact with insureds, injured employee(s), and witnesses when necessary and documents calls, and activities undertaken within the claims system
- Confirms return to work status with insureds
- Confirms appropriate medical care, including use of appropriate cost containment techniques and resources, and takes appropriate actions
- Sets timely, adequate reserves in compliance with the company reserving philosophy and methodology
- Provides prompt, detailed responses to agents, insureds, and injured employee on the status of claims
- Escalates claims to supervisor as appropriate
- Maintains accurate and timely diaries on all files to handle claims and bring a resolution
- Completes state reporting as required within jurisdictional guidelines
- Secures all the necessary reports, claims forms and documents
- Documents claim handling activity via claim notes, including Medicare (MSP) modules in the claims system
- Drafts and sends denial letters upon manager approval
- Issues timely payments within check authority limit
- Submits referrals to Special Investigation, Subrogation, Medical Management, and Medical Review Units as appropriate
- Markets OnCall Nurse (OCN), Return to Work (RTW), Select Preferred Provider (SPP) to insured's and identifies non-use for corrective measures
- Prepares risk reports for Underwriting
- Assists Claims team members with the handling of claims as needed
- Attends and participates in round table discussions as appropriate
- Attends internal and external training and self-study to keep abreast of changes relating to medical treatment, and jurisdictional and statue changes impacting workers compensation benefits
- Associate degree or equivalent relevant experience
- One year of insurance or claims handling experience or related experience
- Bachelor's degree may be considered in lieu of the experience requirement
- Attainment of all applicable state licenses within six months of hire
- Basic knowledge of claims adjusting process preferred
- Good knowledge of computers
- Good investigative and problem-solving abilities
- Ability to multi-task and prioritize deadlines
- Strong organizational, written and verbal communication skills
- Strong customer service skills
- Ability to adhere to high standards of professional conduct and code of ethics
- Ability to maintain confidentiality
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Medical Only Claims Representative - Des Moines, United States - EMC Insurance
Description
At EMC, you'll put your skills to good use as an important member of our team. You can count on gaining valuable experience while contributing to the company's success. EMC strives to hire and retain the best people by engaging, developing and rewarding employees.
**This position can be performed remotely for candidates who reside in ND, MN, WI, MI, RI, OH, NC, MS, TX, AZ, KS, MO, NE, IA, IL, PA.**
Develops decision-making and problem -solving skills to investigate and evaluates medical only (MO) claims within multiple jurisdictions. Reviews the claim notice and policy to verify coverage, deductibles, compensability, and jurisdiction compliance. Confirms appropriate medical care, including use of appropriate cost containment techniques and resources, and takes appropriate actions. Maintains accurate and timely diaries on all files to handle claims and bring to a resolution. Completes state reporting as required within jurisdictional guidelines. Communicates with agents, insureds, and claimants regarding the claim status and resolves basic questions of coverage.
Essential Functions:
Education & Experience:
Knowledge, Skills and Abilities:
Our employment practices are in accordance with the laws that prohibit discrimination due to race, color, creed, sex, sexual orientation, gender identity, genetic information, religion, age, national origin or ancestry, physical or mental disability, medical condition, veteran status, active military status, citizenship status, marital status or any other consideration made unlawful by federal, state, or local laws.
All of our locations are tobacco free including in company vehicles.
