Medical Only Claims Specialist /MOCS I

<strong>AF Group (Lansing, Mich.) and its subsidiaries are a premier provider of innovative insurance solutions. Insurance policies may be issued by any of the following companies within AF Group: Accident Fund Insurance Company of America, Accident Fund National Insurance Company, Accident Fund General Insurance Company, United Wisconsin Insurance Company, Third Coast Insurance Company, or CompWest Insurance Company.</strong>

Lansing, MI

AF Group

<p class="p1"><strong>AF Group&rsquo;s focused and passionate team uses industry-leading best practices, analytics and resources to manage risk and minimize loss for our policyholders while strengthening businesses with our valued independent agent partners.</strong></p> <p class="p1"><strong>We strive to continuously increase the long-term value of our organization by outperforming our industry peers and fostering a culture of underwriting and claims excellence.</strong></p>

keywords: medical only claims specialist i (level 10),medical only claims specialist (level 12),claims,quality assurance,medical,operations,teamwork,compensation,performance,education,experience,knowledge,license and certifications,skills


Competitive Compensation and Benefits Package

Overview: <p><strong>Medical Only Claims Specialist I (Level 10) Job Description:&nbsp;</strong></p> <p><strong>The majority of hours worked are between 8:00 a.m. and 5:45 p.m. EST</strong></p> <p><strong>SUMMARY:&nbsp;</strong></p> <p>This is an entry-level Medical-Only Claims (MOCSI) position that is part of a MOCS training program that is expected to last approximately one year.</p> <p>Primarily responsible for the investigation and management of workers' compensation claims. Conducts a 1 to 3 point contact to triage claims, which is dependent on either the facts of the case or the claim type, 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 Claim Handlers.<br /><br /></p> <p><strong>Medical Only Claims Specialist (Level 12)&nbsp;&nbsp;Job Description</strong></p> <p><strong>SUMMARY:</strong>&nbsp;</p> <p>Primarily responsible for the investigation and management of workers&rsquo; compensation claims. &nbsp;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.</p>
Responsibilities: <ul> <li>Assists with investigation of workers' compensation claims with a mandatory contact to the employer within the required time frame, and with additional contacts to the employee or provider as necessary.&nbsp;</li> <li>Assists with determining and managing the on-going medical treatment program including directing care, creating panels and approving provider requests.</li> <li>Remains abreast of new case law decisions affecting claim and medical management.</li> <li>Monitors the work status of the claimants.</li> <li>Evaluates medical reports and correspondence for appropriate action/documentation.</li> <li>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.</li> <li>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.</li> <li>Determines causal relationship between the reported injury and the incident to ensure appropriate payment of benefits.</li> <li>Documents specifics of claims with potential for subrogation.</li> <li>Manages medical bills for non-indemnity 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.</li> <li>Concludes and closes files following resolution of claims to meet internal performance standards while complying with state legislation to avoid penalties and manage expenses.</li> <li>Coordinates with outside vendors to ensure cost containment efforts.</li> <li>Establishes and maintains effective working relationships with all internal and external customers. Assists with determining appropriate response to regulatory inquiries.</li> <li>Composes correspondence and various reports in the administration of workers compensation claims; sets appropriate diaries.cts employee-employer interviews to assist in the return-to-work proceReads, routes, and keys incoming mail, runs reports and answers/responds to incoming phone calls, faxes and emails.</li> </ul>
Requirements: <p><strong>EDUCATION REQUIRED:</strong></p> <p>Associate degree in insurance, health administration and/or related field. Progress towards or completion of Insurance Institute of America (IIA) or other insurance related designation(s) preferred. Combinations of education and experience may be considered in lieu of a degree.</p> <p><strong>EXPERIENCE REQUIRED:</strong></p> <p>Minimum of three (3) years general office experience including a minimum of one (1) year in insurance or healthcare administration. Relevant customer service experience exchanging information and answering basic inquiries over the phone is required.</p> <p><strong>SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:</strong></p> <ul> <li>General knowledge of insurance operations.</li> <li>Ability to work effectively in a multifunctional business unit.</li> <li>Excellent verbal and written communication skills.</li> <li>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.</li> <li>Ability to effectively exchange information clearly and concisely, and present ideas, report facts and other information and respond to questions as appropriate.</li> <li>Ability to negotiate, build consensus, and resolve conflict.</li> <li>Excellent organizational skills and ability to prioritize work.</li> <li>Ability to manage multiple priorities and meet established deadlines.</li> <li>Ability to perform mathematical calculations.</li> <li>Excellent analytical and problem-solving skills.</li> <li>Ability to use reference manuals.</li> <li>Basic knowledge of medical terminology.</li> <li>Basic knowledge of legal terminology.</li> <li>Ability to comprehend various issues, address them or refer them for appropriate decision-making.</li> <li>Ability to work with minimal direction.</li> <li>Ability to proofread documents for accuracy of spelling, grammar, punctuation and format.</li> </ul> <p><strong>ADDITIONAL EDUCATION, EXPERIENCE, SKILLS, KNOWLEDGE AND/OR ABILITIES PREFERRED:</strong><em>&nbsp;</em></p> <ul> <li>Michigan Claims Adjuster License highly preferred</li> </ul> <div id="gtx-trans" style="position: absolute; left: -115px; top: 26px;">&nbsp;</div>