Under 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
- No attorney involvement or litigation
PRIMARY JOB DUTIES AND RESPONSIBILITIES:
Determining causal relatedness and medical necessity of minor medical conditions/treatment through the use of tools/guidelines (medical guidelines, medical position statements, etc.).
Reviewing, approving and making accurate/timely payment of appropriate medical bills and expenses in compliance with State regulations. Maintain medical bills in file per established guidelines.
Evaluating the need to transfer from medical only to the Investigative Case Unit or Return to Work Unit as appropriate.
Channeling to preferred network as appropriate
Identifying 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.
Completing denials limited to medical issues and communicating denials to impacted parties.
Responding to insured and injured worker inquiries as necessary.
Perform applicable 24 hour contacts on accounts with specifics instructions outlined in Special Account Communications (SAC).
Engage/refer to nurse resource for utilization review when appropriate and or on CM Plus accounts.
File appropriate state forms as required.
Identify the need for a Utilization Review (UR) referral.
Perform other duties as requested.
College degree preferred
1-2 year related business experience a plus (i.e., insurance, customer service, financial, banking)
To acquire after hire, license/certificate if required by state regulations
JOB SPECIFIC TECHNICAL SKILLS AND COMPETENCIES:
- 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-
- Exercises sound judgment, makes decisions and commits
to a position.
- Demonstrates effective verbal, written and listening
- Offers incentives in fair exchange for what they want from
another individual and reaches agreement through
discussion and compromise.
Insurance Contract Knowledge:
- Interprets policies and contracts, applies loss facts to policy
conditions, and determines whether or not a loss comes
within the scope of the insurance contract.
Principles of Investigation:
- Follows a logical sequence of inquiry with a goal of arriving at
an accurate reconstruction of events related to the loss.
- Determines liability and assigns a dollar value based on
damages claimed and estimates, sets and readjusts
- Assesses how a claim will be settled, when and when not to
make an offer, and what should be included in the settlement
- Knowledge understanding and application of state, federal
and regulatory laws and statutes, rules of evidence, chain of
custody, trial preparation and discovery, court proceedings,
and other rules and regulations applicable to the insurance
- Learns and applies specialized information to evaluate the
nature and extent of injury.
- Expresses, summarizes and records thoughts clearly and
concisely orally and in writing by applying proper content,
format, sentence structure, grammar, language and
- Exceptional Customer Service skills
- Strong organizational skills
- Ability to build and maintain productive relationships
- Strong computer skills
Operates standard office equipment
Requires lifting items between 1 - 5 pounds.
Requires extended periods of computer use
Requires extended periods of sitting
Travelers is an equal opportunity employer. We actively promote a drug-free workplace.
Travelers Co - 10 months ago