Medical Only Claims Spec I/II

Medical Only Claims Specialist

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 include investigating workers' compensation claims, documenting claim files, verifying workers' compensation coverage, determining and managing the ongoing medical treatment program, remaining abreast of new case law decisions affecting claim and medical management, monitoring the work status of injured workers, evaluating medical reports and correspondence for appropriate action/documentation, supporting customer service work and processes for the multi-functional claims team, handling multiple jurisdictions based on team needs, establishing timely and appropriate reserves based on the profile of the claim, determining causal relationship between the reported injury and the incident, documenting specifics of claims with potential for subrogation recovery, assisting subro representative with investigation, engaging ISU to obtain police reports, approving, editing, and denying payment based on knowledge of the treatment plan and medical support, concluding and closing files following resolution of claims, coordinating with outside vendors to ensure cost containment efforts, establishing and maintaining effective working relationships with all internal and external customers, coordinating all efforts with proprietary technology, determining appropriate response to regulatory inquiries, composing correspondence and various reports in the administration of workers compensation claims, reading, routing and keying incoming mail, running reports and answering/responding to incoming phone calls, scheduling independent medical evaluations, staying abreast of changes in workers' compensation statutes, case law and rehabilitation efforts/advancements, handling telephonic mediations to avoid litigation, communicating with plaintiff's attorney and providing limited records to potentially avoid unnecessary litigation, managing prescription requests, medical treatment, and ongoing return to work options for injured employees, facilitating return to work for the injured employee and monitoring work status on medical only claims with a keep at work focus, serving as an adjuster to the dedicated account representative, acting as a back up to the MOCS, and Claims Representatives, setting the initial reserve and any subsequent changes on indemnity files, approving, editing and denying medical bills for non-indemnity and indemnity claims, conducting employee-employer interviews to assist in the return-to-work process, supporting the account management process appropriately for the team's block of business, initiating indemnity payments and monitoring for items such as age reduction, coordination of benefits, Stozicki, Second Injury Fund, dependent drops and supplemental payments, monitoring rate of life expectancy and update/monitor reserves accordingly, compiling annual CAT assessments and reviewing with appropriate parties, evaluating cases for Stokes and PRIUM, coordinating with outside vendors to ensure cost containment efforts, and working closely with manager on complex files or files above reserve authority.

Additional responsibilities for a Medical Only Claims Specialist II include training and mentoring other team members, mentoring fellow team members and assisting in their development as a MOCS, working with minimum supervision, and attending agent and/or policyholder visits.

Employment qualifications include a high school diploma, MI or TX license required with 180 days of start date for Medical Only Claims Specialist I, and an 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) and MI or TX license required for Medical Only Claims Specialist II.

Skills/knowledge/abilities required include general knowledge of claims operations specifically claims processes, ability to work effectively in a multifunctional business unit, excellent verbal and written communication skills, ability to use diplomacy, discretion, and appropriate judgment when responding to inquiries from staff and external customers, 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, ability to manage multiple priorities and meet established deadlines, 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, ability to work with minimal direction, and ability to travel to locations outside of the office.

Additional skills/knowledge/abilities required for MOCS II include demonstrated ability to use diplomacy, discretion, and appropriate judgment when responding to inquiries from staff and external customers, 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.

Preferred education, experience, skills, knowledge and/or abilities include progress towards or completion of Insurance Institute of America (IIA) or other insurance related designation(s).

Working conditions include work performed in an office setting with no unusual hazards, and 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).