Medical Only Claims Specialist 1/2

SUMMARY: (Brief 3-5 sentence paragraph outlining the main purpose of the job)

The Medical Only Claims Specialist I is an entry level claims role. The incumbent is expected to be proficient with the Claims unit, policies, processes, procedures, and terminology. 

The Medical Only Claims Specialist II is an experienced level claims role. The incumbent is expected to perform at a high level with minimum supervision.

Primarily responsible for the investigation and management of workers’ compensation claims. Conducts a 1 to 3-point contact on the managed claims, which is dependent on either the facts of the case or the claim type;determines compensability of claims, manages the medical treatment program, and assists in the return-to-work process. This includes calling and discussing potential claim activity and work-related injuries with policyholders, claimants, providers, attorneys, agents, and state agencies. Trains and mentors other team members. Provides backup support to other Claim Handlers.

PRIMARY RESPONSIBILITIES: (Brief bullet points detailing the major duties, not tasks, for this job and the % of time spent on each. Please list them in the order of importance)

• Investigates workers’ compensation claims with a mandatory contact to the employer within the required time frame with additional contacts to the employee or provider, as necessary.   

• Documents claim file.

• Verifies workers’ compensation coverage (statutory and policy) of employers and injured employees.  

• Determines, documents, and manages the on-going medical treatment program including directing care, creating jurisdictional specific panels, and approving provider requests. 

• Remains abreast of new case law decisions affecting claim and medical management.

• Monitors the work status of the injured workers.

• Evaluates medical reports and correspondence for appropriate action/documentation

• Supports the customer service work and processes for the multi-functional claims team; Communicates and collaborates with team members to ensure the appropriate and timely handling of claims in other states.

• May be required to handle multiple jurisdictions based on team needs.

• Establishes timely and appropriate reserves based on the profile of the claim within given authority based on anticipated financial exposure. Documents in the claim file the basis for reserve calculations. 

• Determines causal relationship between the reported injury and the incident to ensure appropriate payment of benefits.

• Documents specifics of claims with potential for subrogation recovery 

• Assists Subro representative with investigation. 

• Engages ISU to obtain police reports.

• Approves, edits, and denies payment based on knowledge of the treatment plan and medical support showing relationship of treatment to the injury.

• Concludes and closes files following resolution of claims to meet internal performance standards while complying with state legislation to avoid penalties and manage expenses.

• Coordinates with outside vendors to ensure cost containment efforts. 

• Establishes and maintains effective working relationships with all internal and external customers. Assists with determining appropriate response to regulatory inquiries.

1. Coordinates all efforts with proprietary technology, including causation investigations, Care Analytics, and future models.  

1. Determines appropriate response to regulatory inquiries and completes statutory filings, including EDI data completion

• Composes correspondence and various reports in the administration of workers compensation claims; sets appropriate diaries. 

• Reads, routes and keys incoming mail, runs reports and answers/responds to incoming phone calls on both direct and ACD line, faxes, and emails. This may include completing work for peers during absences to provide uninterrupted service to customers.

• Schedules independent medical evaluations provides synopsis and outlines all questions to IME physician. Upon receipt of results, communicates to all parties, facilitates future treatment, or may result in formal denials being filed

• Assigns ISU to complete causation investigation

• Stays abreast of changes in workers’ compensation statutes, case law and rehabilitation efforts/advancements to accurately interpret and apply relevant laws.

• Handles telephonic mediations to avoid litigation.

• Communicates with plaintiff’s attorney and provides limited records to potentially avoid unnecessary litigation. Active litigation is transferred to another team. May handle mediation or teleconference dependent on the circumstances

• Manages prescription requests, medical treatment, and ongoing return to work options for injured employees

• Facilitates return to work for the injured employee and monitors work status on medical only claims with a keep at work focus.

• May serve as an adjuster to the dedicated account representative 

• Supports the team, as required, by acting as a back up to the MOCS, and Claims Representatives.

• Responsible to set the initial reserve and any subsequent changes on indemnity files.

• Approves, edits and denies medical bills for non-indemnity and indemnity claims directly associated with the claimed injury based on knowledge of the treatment plan and medical support showing relationship of treatment to the injury.

• Conducts employee-employer interviews to assist in the return-to-work process. 

• Supports the account management process appropriately for the team’s block of business.

ADDITIONAL RESPONSIBILITIES FOR A MEDICAL ONLY CLAIMS SPECIALIST II:

• Trains and mentors other team members.

• Mentors fellow team members and assists in their development as a MOCS

• Works with minimum supervision.

• May attend agent and/or policyholder visits.

ADDITIONAL PRIMARY RESPONSIBILITIES FOR MAINTENANCE:

1. Initiates indemnity payments and monitors for items such as age reduction, coordination of benefits, Stozicki, Second Injury Fund, dependent drops and supplemental payments.

1. Monitors rate of life expectancy and update/monitor reserves accordingly.

1. Compiles annual CAT assessments and reviewing with appropriate parties.

1. Evaluates cases for Stokes and PRIUM.

1. Coordinates with outside vendors to ensure cost containment efforts

1. Works closely with manager on complex files or files above reserve authority.  

This description identifies the responsibilities typically associated with the performance of the job. The percentage of time in any responsibility may vary between positions.  Other relevant essential functions may be required.

EMPLOYMENT QUALIFICATIONS:

1. EDUCATION REQUIRED: (Brief paragraph detailing the minimum education required, including certifications) Do not state preferred qualifications.

MEDICAL ONLY CLAIMS SPECIALIST I:

High school diploma

MI or TX license is required with 180 days of start date*

*see notes below

MEDICAL ONLY CLAIMS SPECIALIST II:

Associate degree in insurance and/or related field with progress towards or completion of Insurance Institute of America (IIA) or other insurance related designation(s). Combinations of education and experience may be considered in lieu of a degree.

MI or TX license required.

1. EXPERIENCE REQUIRED: (Minimum experience required to perform this job) Do not state preferred experience.

MEDICAL ONLY CLAIMS SPECIALIST I:

Successful completion of Medical Only Claims Specialist training program. 

OR

30 credit hours towards an Associate’s degree in insurance, business administration, health administration and/or a related field. Minimum of Two (2) years insurance experience, including one (1) year of demonstrated technical knowledge (i.e. applying relevant workers compensation laws, regulations, guidelines, and/or policies that would impact claims and/or underwriting outcomes). Relevant customer service experience exchanging information and answering and resolving inquiries over the phone. Combination of education and experience may be considered in lieu of a credit hours.

OR

Associate’s degree in insurance, business administration, health administration and/or related field with progress towards or completion of Insurance Institute of America (IIA) or other insurance related designation(s) and two (2) years of insurance experience including one (1) year experience in a property & casualty claims role (i.e. applying regulations, guidelines, and/or policies that would impact claims and/or underwriting outcomes in a property & casualty environment). Combination of education and experience may be considered in lieu of a degree.

MEDICAL ONLY CLAIMS SPECIALIST II (MOCS II):

1 years’ experience as a MOCS I with demonstrated competency in multiple jurisdictions. 

OR

Minimum of three (3) years insurance experience. Two (2) years of demonstrated technical knowledge (i.e. applying relevant workers compensation laws, regulations, guidelines, and/or policies that would impact claims and/or underwriting outcomes) including one (1) year managing workers' compensation claims required. Relevant customer service experience exchanging information and answering and resolving inquiries over the phone required.

1. SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED: (Brief bullet points detailing the skills, knowledge, and abilities required for this job. SKA’s should tie back to the primary responsibilities required)

1. General knowledge of claims operations specifically claims processes.

1. Ability to work effectively in a multifunctional business unit.

1. Excellent verbal and written communication skills.

1. Ability to use diplomacy, discretion, and appropriate judgment when responding to inquiries from staff and external customers as well as anticipating needs of the department.

1. Ability to effectively exchange information clearly and concisely, and present ideas, report facts and other information and respond to questions as appropriate.

• Basic knowledge of Workers Compensation in one or more states including jurisdictional laws. 

• Basic knowledge of statutory standards in multiple states.

• Ability to apply relevant workers’ compensation laws and regulations, including jurisdictional laws.

• Ability to negotiate, build consensus, and resolve conflict.

• Excellent organizational skills and ability to prioritize work.

1. Ability to manage multiple priorities and meet established deadlines.

1. Ability to perform mathematical calculations.

• Excellent analytical and problem-solving skills.

• Ability to use reference manuals.

• Knowledge of medical terminology.

• Knowledge of legal terminology.

• Ability to comprehend various claims issues, address them or refer them for appropriate decision-making.

• Ability to analyze details of workers compensation claims and as a result able to make competent, independent decisions within authority.

1. Ability to work with minimal direction.

1. Ability to travel to locations outside of the office.

1. Ability to proofread documents for accuracy of spelling, grammar, punctuation, and format.

ADDITIONAL SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED FOR MOCS II:

• Demonstrated ability to use diplomacy, discretion, and appropriate judgment when responding to inquiries from staff and external customers as well as anticipating needs of the department. 

• Demonstrated ability to effectively exchange information clearly and concisely, and present ideas, report facts and other information and respond to questions as appropriate.

• Knowledge of Workers Compensation in one or more states including jurisdictional laws.

• Knowledge of statutory standards in multiple states.

• Demonstrated ability to negotiate, build consensus, and resolve conflict.

• Demonstrated ability to manage multiple priorities and meet established deadlines.

• Demonstrated ability to comprehend various claims issues, address them or refer them for appropriate decision-making.

• Demonstrated ability to analyze details of workers compensation claims and as a result able to make competent, independent decisions within authority.

• Demonstrated ability to work with minimal direction.

1. ADDITIONAL EDUCATION, EXPERIENCE, SKILLS, KNOWLEDGE AND/OR ABILITIES PREFERRED: (Briefly detail the preferred education, experience, skills, knowledge and/or abilities desired to perform this job, including certifications). These are in addition to the required qualifications - Do not state required qualifications.

1. Progress towards or completion of Insurance Institute of America (IIA) or other insurance related designation(s) preferred

WORKING CONDITIONS:

Work is performed in an office setting with no unusual hazards.

May be required to obtain reciprocal licenses in any jurisdiction requiring a license and managed by the AFICA Medical Only Claims Team (may be required to travel, submit to a background check, or provide personal information in order to obtain these licenses)

MEDICAL ONLY CLAIMS SPECIALIST I NOTES: