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Medical Only Claims Specialist in Lansing, MI at AF Group

Date Posted: 10/9/2018

Job Snapshot

Job Description

 Medical Only Claims Specialist Worker's Compensation- Lansing - Servicing Carrier

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. Provides backup support to other MOCS and Claims Representatives; trains and mentors other team members.

  • 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.
  • Determines the compensability of medical only and pay and close indemnity claims by thorough investigation of the claim.
  • Determines and manages the on-going medical treatment program including directing care, creating panels and approving provider requests.
  • Remains abreast of new case law decisions affecting claim and medical management.
  • Handles telephonic mediations to address litigated issues.
  • Monitors the work status of the claimants.
  • May serve as an adjuster to the dedicated account representative.
  • 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.
  • Supports the team, as required, by acting as a back up to the Service Center, MOCS, and Claims Representatives.
  • Mentors fellow team members and assists in the development of individual career paths.
  • Establishes timely and appropriate reserves based on the profile of the claim within given authority based on anticipated financial exposure.
  • Verifies workers' compensation coverage of employers and injured employees.
  • 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, including amount of potential recovery monies.
  • Manages medical bills for non-idemnity and indemnity claims directly associated with the claimed injury. Approves 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.
  • Works closely with manager on complex files or files above reserve authority.
  • Coordinates with outside vendors to ensure cost containment efforts.
  • Establishes and maintains effective working relationships with all internal and external customers.
  • Coordinates the Care Analytics and causation investigation initiatives as deemed appropriate by using tools such as Thru Time model, Claim Outcome model, Claim Predict Litigation models, and pharmacy program.
  • Determines appropriate response to regulatory inquiries.
  • Composes correspondence and various reports in the administration of workers compensation claims; sets appropriate diaries.
  • May attend agent and/or policyholder visits.
  • 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.
  • Recommends independent medical evaluations within authority.
  • Reads, routes and keys incoming mail, runs reports and answers/responds to incoming phone calls, faxes and emails.
  • Works with minimum supervision.


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