Workers Compensation Medical Only Claim Specialist

Claim

Under moderate to direct supervision, this position is responsible for: Reviewing/evaluating, approving and processing Medical Only claims with: No lost time beyond statutory waiting period, No salary continuation, A return to full time work within 90 days if the injured worker is on modified duty and/or total medical paid generally not to exceed $5,000. No attorney involvement or ongoing litigation. As part of the hiring process, this position requires the completion of an online pre-employment assessment. Further information regarding the assessment including an accommodation process, if needed, will be provided at such time as your candidacy is deemed appropriate for further consideration.

What Will You Do?

• Identify red flags or other issues, such as medical treatment in excess of 180 days or $5,000 in medical expenses, or 90 days if the injured worker is on modified duty.
• Evaluate the need to transfer from medical only to the Investigative Case Unit or Return to Work Unit as appropriate.
• Respond to insured and injured worker and provider inquiries as necessary.
• Determine causal relatedness and medical necessity of minor medical conditions/treatment through the use of tools/guidelines (medical guidelines, medical position statements, etc.).
• Coordinate medical treatment as appropriate:
• Review, approve and make accurate/timely payment of appropriate medical bills and expenses in compliance with State regulations.
• Channel to preferred network as appropriate.
• Complete denials limited to medical issues and communicate denials to impacted parties.
• Identify the need for and engage nurse resource for utilization review when appropriate.
• File appropriate state forms.
• In order to perform the essential functions of this job, acquisition and maintenance of Insurance License(s) may be required to comply with state and Travelers requirements. Generally, license(s) must be obtained within three months of starting the job and obtain ongoing continuing education credits as mandated.
• Maintain Continuing Education requirements as required.
• Perform other duties as assigned.

What Will Our Ideal Candidate Have?

• College degree.
• 1-2 year related business experience.
• Analytical Thinking: Identifies current or future problems or opportunities; analyzes, synthesizes and compares information to understand issues; identifies cause/effect relationships; and explores alternative solutions that support sound decision-making.
• Strong attention to detail.
• Judgment/Decision Making: Exercises sound judgment.
• Makes decisions and commits to a position.
• Communication: Able to communicate information in terms that can be easily understood by others.
• Expresses, summarizes and records thoughts clearly and concisely orally and in writing by applying proper content, format, sentence structure, grammar, language and terminology.
• Negotiation: Ability to understand alternatives, influence stakeholders and reach a fair agreement through discussion and compromise.
• Principles of Investigation: Follows a logical sequence of inquiry with a goal of arriving at an accurate reconstruction of events related to the loss.
• Legal Knowledge: General knowledge, understanding and application of state, federal and regulatory laws and statutes related to Workers' Compensation.
• Medical knowledge: General knowledge of the nature and extent of injuries, periods of disability, and treatment needed.
• Customer Service: Demonstrated ability to build and maintain productive relationships with our insureds and deliver results with optimal outcomes.
• Teamwork: Advanced ability to work together in situations when actions are interdependent and a team is mutually responsible to produce a result.
• Planning & Organizing: Advanced ability to establish a plan/course of action and contingencies for self or others to meet current or future goals.

What Is a Must Have?

• High School Diploma or GED and one year of customer service experience OR Bachelor's Degree.

What Is in It for You?

• Health Insurance: Employees and their eligible family members including spouses, domestic partners, and children are eligible for coverage from the first day of employment.
• Retirement: Travelers matches your 401(k) contributions dollar-for-dollar up to your first 5% of eligible pay, subject to an annual maximum. If you have student loan debt, you can enroll in the Paying it Forward Savings Program. When you make a payment toward your student loan, Travelers will make an annual contribution into your 401(k) account. You are also eligible for a Pension Plan that is 100% funded by Travelers.
• Paid Time Off: Start your career at Travelers with a minimum of 20 days Paid Time Off annually, plus nine paid company Holidays.
• Wellness Program: The Travelers wellness program is comprised of tools, discounts and resources that empower you to achieve your wellness goals and caregiving needs. In addition, our mental health program provides access to free professional counseling services, health coaching and other resources to support your daily life needs.
• Volunteer Encouragement: We have a deep commitment to the communities we serve and encourage our employees to get involved. Travelers has a Matching Gift and Volunteer Rewards program that enables you to give back to the charity of your choice.

Employment Practices

Travelers is an equal opportunity employer. We value the unique abilities and talents each individual brings to our organization and recognize that we benefit in numerous ways from our differences. In accordance with local law, candidates seeking employment in Colorado are not required to disclose dates of attendance at or graduation from educational institutions. If you are a candidate and have specific questions regarding the physical requirements of this role, please send us an email so we may assist you. Travelers reserves the right to fill this position at a level above or below the level included in this posting. To learn more about our comprehensive benefit programs please visit http://careers.travelers.com/life-at-travelers/benefits/.