Job Description

SUMMARY: (Brief 3-5 sentence paragraph outlining the main purpose of the job)

This is an entry-level position. This position leads to a Medical Only Claims Specialist I and is expected to last up to 12 months. Upon completion of the training plan the incumbent is expected to be proficient with the Medical Only Claims policies, processes, procedures, and terminology related to the job. In addition, the incumbent will be proficient in the job responsibilities and tasks of the Medical Only Claims Specialist I position description. The incumbent will be evaluated on their progress and successful completion of the training plan each quarter. Upon satisfactory completion, the incumbent will be eligible for the Medical Only Claims Specialist I position. Medical Only Claims Associate will work with all members of the team and may receive direction, support, and instruction from the Manager or Medical Only Claims Specialists depending on the assignment.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

1. Assist Medical Only Claims Specialist with the investigation and management of workers compensation claims.
2. Assists with determining and managing the on-going medical treatment program including directing care, creating panels, and approving provider requests.
3. Evaluates medical reports and correspondence for appropriate action/documentation.
4. 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.
5. May be required to act as a back up to the MOCS. For items such as Verifies workers’ compensation coverage of employers and injured employees.
6. Documents specifics of claims with potential for subrogation.
7. Approves payment based on knowledge of the treatment plan and medical support showing relationship of treatment to the injury.
8. Concludes and closes files following resolution of claims to meet internal performance standards while complying with state legislation to avoid penalties and manage expenses.
9. Coordinates with outside vendors to ensure cost containment efforts.
10. Establishes and maintains effective working relationships with all internal and external customers. Assists with determining appropriate response to regulatory inquiries.
11. Composes correspondence and various reports in the administration of workers compensation claims; sets appropriate diaries.
12. Reads, routes and keys incoming mail, runs reports and answers/responds to incoming phone calls on both direct and ACD line, faxes and emails. This may include completing work for peers during absences to provide uninterrupted service to customers.
13. Demonstrate growth of skills working towards the more complex responsibilities of the Medical Only Claims Specialist I position.
14. Increase knowledge of how Accident Fund Insurance Company of America runs and how Workers Compensation Insurance works.

EDUCATION AND EXPERIENCE

Relevant combination of education and experience may be considered in lieu of degree

1. High school diploma
2. 2 years insurance experience (Could add finance, medical, or any other applicable experience)

OR

1. Associates degree in insurance, business administration, health administration and/or related field. Combination of education and experience may be considered in lieu of a degree.

QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

OTHER SKILLS AND ABILITIES

1. General knowledge of insurance operations.
2. Ability to work effectively in a multifunctional business unit.
3. Excellent verbal and written communication skills.
4. Ability to use diplomacy, discretion, and appropriate judgment when responding to inquiries from staff and external customers as well as anticipating needs of the department.
5. Ability to effectively exchange information clearly and concisely, and present ideas, report facts and other information and respond to questions as appropriate.
6. Ability to negotiate, build consensus, and resolve conflict.
7. Excellent organizational skills and ability to prioritize work.
8. Ability to manage multiple priorities and meet established deadlines.
9. Ability to perform mathematical calculations.
10. Excellent analytical and problem solving skills.
11. Ability to use reference manuals.
12. Basic knowledge of medical terminology.
13. Ability to comprehend various issues, address them or refer them for appropriate decision-making.
14. Ability to work with minimal direction.
15. Ability to proofread documents for accuracy of spelling, grammar, punctuation, and format.
16. ADDITIONAL EDUCATION, EXPERIENCE, SKILLS, KNOWLEDGE AND/OR ABILITIES PREFERRED: (Briefly detail the preferred education, experience, skills, knowledge and/or abilities desired to perform this job, including certifications). These are in addition to the required qualifications - Do not state required qualifications.

• Associates degree preferred
• Progress towards or completion of Insurance Institute of America (IIA) or other insurance related designation(s) preferred

WORKING CONDITIONS:

Work is performed in an office setting with no unusual hazards.

REQUIRED TESTING: (For HR use only)

Reading Comprehension, Typing 35wpm, Basic Word, Math and Proofreading.

Internal Candidate: An incumbent who does not successfully obtain a MI or TX licenses at the end of the 180 days will not be placed in a MOCS role. If the Company is unable to return the incumbent to a bargaining-unit job the incumbent will then be placed on the recall list in accordance with Article 8.8 of the Collective Bargaining Agreement.

External Candidate: Initial probationary period 180 days. Successful completion of probationary period requires adjuster license obtained in either MI or TX.

NOTES:

An incumbent who does not successfully complete the training plan at the end of the 12 months will not be placed in a Medical Only Claims Specialist I position. If the Company is unable to return the incumbent to a bargaining-unit job the incumbent will then be placed on the recall list in accordance with Article 8.8 of the Collective Bargaining Agreement.

ADDITIONAL INFORMATION

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. This job description does not constitute a contract for employment.

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