Job Title: Medical Services Specialist
Job ID: 03056
Division : Claims Operations
Work Location(s): United States-Colorado-Englewood
Full/Part Time: Full-Time
The Medical Services Specialist reviews files to identify medical legal issues. Prepares file summaries and complex reviews of medical claim information on Casualty/Bodily Injury files for Claims in a variety of high impact areas. Provides medical document summaries and critiques complicated, complex files for settlement factors, negotiation, discovery, and trial preparation. Facilitates continuous development of people, processes, and culture to ensure customer service industry leadership.
- Medical Claim Review and Analysis (80%)
- Provides a summary document for claims professional, assigned in-house attorney or outside counsel. This document includes concise medical record summary of all medical treatment. The format of the document is easily readable for interpretation by non-medical professionals. Generates appropriate reports and summaries related to the claim file.
- Critiques the medical-legal issues in the file as to relatedness to the accident and evaluates issues regarding severity. Communicates concerns and recommendations before settlement and for trial preparation.
- Identifies settlement factors useful in negotiations or trial preparations such as, but not limited to preexisting factors and pre-accident health status, injuries from either repetitive incidents or incidents following the accident.
- Assesses need for independent medical exam (IME) and type of examiner needed. Writes a summary and formulates specific questions. As needed works with the referring attorney to develop questions and issues for the examiner to address.
- Reviews Worker's Compensation files, assesses need for medical case management, and coordinates with those performing case management roles.
- Evaluates appropriateness and necessity of services on a current and future basis, using extensive medical knowledge and experience or use of consultants.
- Education and Training (10%)
- Trains new Medical Services personnel, as requested by manager.
- Provides general education of Medical Services program and advanced medical topics to various groups inside and outside the company as assigned by manager.
- Researches and summarizes medical topics. This may involve texts and other resources as well as computer searches at local hospitals or university medical centers.
- Serves as an expert for medical bill processing software.
- Fraud Investigation (5%)
- Identifies cases which may involve fraud, malpractice, or other flagrant abuses and alerts manager.
- Identifies billing or treatment trends and alerts manager of such trends.
- Completes medical investigations and aids the adjuster with the referral to Special Investigative Unit (SIU) or other resources as necessary. Provides suggestions of what is needed in providing an understanding of the items acquired.
- Coordinates information with other lines, SIU and regions as appropriate.
- Assists manager in preparation of file and data for legal or enforcement agency referral.
- Cooperates with external enforcement agencies within state or national corporate and regional guidelines.
- Special Projects (5%)
- Supports and advises regional legal counsel at small claims court or arbitration. As required, may serve on local office task teams, regional task teams, Rules Committee, Steering Committee (medical bill audit software), and Worker's Compensation Committee.
- Assists claim adjusters in the PIP area with all medical aspects of the file.
- Serves as an advisor to claims professionals, manager and attorneys on the medical aspect of highly complex files, including Workers Compensation, committee files, or other high damage claims.
- Researches PPO, direct provider, or other managed case options as assigned. Maintains consultant list and recruits new physicians. Performs preliminary evaluation of consultants and independent medical exam (IME) performance.
- Back up to Medical Services Unit Manager as needed. Researches special projects at the direction of manager.
- Achieve Results
- Be Accountable
- Maximize Customer Experience
- Concern for Quality
- Planning & Organizing
- Relationship Building
- Technical Expertise
Specialized Knowledge and Skills Requirements
- Must maintain a full current, active and unrestricted registered nurses license.
- Ability to work/interface with diverse professionals in the legal and health care fields and public groups in sensitive situations. Requires skill in tact and diplomacy.
- Clinical experience in a healthcare setting.
- Maintains standards of professionalism of the position from a medical/legal standpoint.
- Must be willing to travel for Catastrophe duty if necessary.
- This position requires travel up to 25% of the time.
Offer to selected candidate will be made contingent on the results of background checks.
We offer a comprehensive benefits package that includes health, life and dental insurance, a 401(K) plan, paid holidays, vacation and sick leave and the opportunity for career development. If you would like to put your career in motion apply online today!
A career move to join American Family Insurance may also mean a physical move for you. If you are selected for an interview, information will be provided on the level of relocation assistance available during the interview.
Please review the job requirements.
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