Medical Only Claims Specialist

<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, USA

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>

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Competitive Compensation and Benefits Package

Overview: <br />Primarily responsible for the investigation and management of workers&rsquo; 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.<br /><br /> <p><strong>WORKING CONDITIONS:</strong></p> <p>Work is performed in an office setting with no unusual hazards. Travel may be required.</p> <p><strong>REQUIRED TESTING:&nbsp;</strong>Reading Comprehension, Typing 35wpm, Basic Word, Math, and Proofreading.</p>
Responsibilities: <br /> <ul> <li>Investigates workers&rsquo; compensation claims with a mandatory contact to the employer within the required time frame with additional contacts to the employee or provider, as necessary.&nbsp;</li> <li>Determines the compensability of medical-only and pay and close indemnity claims by thorough investigation of the claim.</li> <li>Determines and manages the ongoing 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>Handles telephonic mediations to address litigated issues.</li> <li>Monitors the work status of the claimants.</li> <li>May serve as an adjuster to the dedicated account representative.</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>Supports the team, as required, by acting as a backup to the Service Center, MOCS, and Claims Representatives.</li> <li>Mentors fellow team members and assists in the development of individual career paths.</li> <li>Establishes timely and appropriate reserves based on the profile of the claim within given authority based on anticipated financial exposure.</li> <li>Verifies workers&rsquo; 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 recovery, including amount of potential recovery monies.</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>Works closely with manager on complex files or files above reserve authority.&nbsp;</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.</li> <li>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.</li> <li>Determines appropriate response to regulatory inquiries.</li> <li>Composes correspondence and various reports in the administration of workers' compensation claims; sets appropriate diaries.</li> <li>May attend agent and/or policyholder visits.</li> <li>Conducts employee-employer interviews to assist in the return-to-work process.</li> <li>Supports the account management process appropriately for the team&rsquo;s block of business.</li> <li>Recommends independent medical evaluations within authority.</li> <li>Reads, routes, and keys incoming mail, runs reports and answers/responds to incoming phone calls, faxes, and emails.</li> <li>Works with minimum supervision.</li> </ul> <div><br /><strong><u><br /><br />ADDITIONAL PRIMARY RESPONSIBILITIES FOR MAINTENANCE:</u></strong><br /><br /> <ul> <li>Initiates indemnity payments and monitors for items such as age reduction, coordination of benefits, Stozicki, Second Injury Fund, dependent drops, and supplemental payments.</li> <li>Monitors rate of life expectancy and update/monitor reserves accordingly.</li> <li>Compiles annual CAT assessments and reviewing with appropriate parties.</li> <li>Evaluates cases for Stokes and PRIUM.</li> </ul> </div>
Requirements: <strong><br />EDUCATION REQUIRED:</strong><br /> <ul> <li>Associate's degree in insurance and/or related field with progress towards or completion of Insurance Institute of America (IIA) or other insurance-related designation(s).</li> <li>Combinations of education and experience may be considered in lieu of a degree.</li> </ul> <br /><br /><br /><strong>EXPERIENCE REQUIRED:</strong><br /> <ul> <li>Minimum of five (5) years of workers' compensation experience, including three (3) years of demonstrated technical knowledge (i.e. applying relevant workers compensation laws, regulations, guidelines, and/or policies that would impact claims and/or underwriting outcomes) required. Relevant customer service experience exchanging information and answering and resolving inquiries over the phone required.</li> </ul> <p>OR</p> <ul> <li>Bachelor&rsquo;s degree in insurance and/or related field with progress towards or completion of Insurance Institute of America (IIA) or other insurance-related designation(s) and three years of insurance experience including two years experience as a claims representative with experience in reviewing, investigating, and managing claims.</li> </ul> <br /><br /><br /><strong>SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:&nbsp;</strong><br /> <ul> <li>General knowledge of claims operations specifically claims processes.</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>Knowledge of Workers' Compensation in one or more states including jurisdictional laws.</li> <li>Basic knowledge of statutory standards in multiple states.</li> <li>Ability to apply relevant workers&rsquo; compensation laws and regulations, including jurisdictional laws.</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>Knowledge of medical terminology.</li> <li>Knowledge of legal terminology.</li> <li>Ability to comprehend various claims issues, address them or refer them for appropriate decision-making.</li> <li>Ability to analyze details of workers' compensation claims and as a result able to make competent, independent decisions within authority.</li> <li>Ability to work with minimal direction.</li> <li>Ability to travel to locations outside of the office.</li> <li>Ability to proofread documents for accuracy of spelling, grammar, punctuation, and format.</li> </ul> <br /><strong><br />ADDITIONAL EDUCATION, EXPERIENCE, SKILLS, KNOWLEDGE, AND/OR ABILITIES PREFERRED:</strong><br /><br /> <ul> <li>Michigan Claims Adjuster License highly preferred</li> <li>Knowledge and experience in claims adjusting, including investigations, determining compensability, and medical management of claims highly preferred.</li> <li>Claims adjuster certification is highly preferred and encouraged.</li> </ul>