Medical Only Claims Specialist 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, 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 /> <p>The Medical Only Claims Specialist I is an entry-level claims role. The incumbent is expected to be proficient with the Claims unit, policies, processes, procedures, and terminology.</p> <p>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. Trains and mentors other team members. Provides backup support to other Claim Handlers.<br /><br /><br /></p> <p><strong>WORKING CONDITIONS:</strong></p> <p>Work is performed in an office setting with no unusual hazards.</p> <p>May be required to obtain reciprocal licenses in any jurisdiction requiring a license and managed by the AFICA Medical Only Claims Team (may be required to travel, submit to a background check, or provide personal information in order to obtain these licenses)</p> <p><strong>REQUIRED TESTING:&nbsp;</strong></p> <p><a target="_blank">Reading Comprehension, Typing 35wpm, Basic Word, Math and Proofreading.</a></p> <p>&nbsp;</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;&nbsp;</li> <li>Documents claim file.</li> <li>Verifies workers&rsquo; compensation coverage (statutory and policy) of employers and injured employees.&nbsp;</li> <li>Determines, documents, and manages the ongoing medical treatment program including directing care, creating jurisdictional-specific 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 injured workers.</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 handle multiple jurisdictions based on team needs.</li> <li>Establishes timely and appropriate reserves based on the profile of the claim within given authority based on anticipated financial exposure. Documents in the claim file are the basis for reserve calculations.</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</li> <li>Assists Subro representative with investigation.</li> <li>Engages ISU to obtain police reports.</li> <li>Approves, edits, and denies payment based on knowledge of the treatment plan and medical support showing relationship of treatment to the injury.</li> <li><a target="_blank">Concludes and closes files following resolution of claims to meet internal performance standards while complying with state legislation to avoid penalties and manage expenses.</a></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>Coordinates all efforts with proprietary technology, including causation investigations, Care Analytics, and future models.&nbsp;</li> <li>Determines appropriate response to regulatory inquiries and completes statutory filings, including EDI data completion</li> <li><a target="_blank">Composes correspondence and various reports in the administration of workers' compensation claims; sets appropriate diaries.</a></li> <li>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.</li> <li>Schedules independent medical evaluations provides synopsis and outlines all questions to IME physician. Upon receipt of results, communicates to all parties, facilitates future treatment, or may result in formal denials being filed</li> <li>Assigns ISU to complete causation investigation</li> <li>Stays abreast of changes in workers&rsquo; compensation statutes, case law and rehabilitation efforts/advancements to accurately interpret and apply relevant laws.</li> <li>Handles telephonic mediations to avoid litigation.</li> <li>Communicates with plaintiff&rsquo;s attorney and provides limited records to potentially avoid unnecessary litigation. Active litigation is transferred to another team. May handle mediation or teleconference dependent on the circumstances</li> <li>Manages prescription requests, medical treatment, and ongoing return-to-work options for injured employees</li> <li>Facilitates return to work for the injured employee and monitors work status on medical-only claims with a keep-at-work focus.</li> <li>May serve as an adjuster to the dedicated account representative</li> <li>Supports the team, as required, by acting as a backup to the MOCS, and Claims Representatives.</li> <li>Responsible to set the initial reserve and any subsequent changes on indemnity files.</li> <li>Approves, edits and denies medical bills for non-indemnity and indemnity claims directly associated with the claimed injury based on knowledge of the treatment plan and medical support showing relationship of treatment to the injury.</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> </ul> <p>&nbsp;</p> <p><strong><u>ADDITIONAL PRIMARY RESPONSIBILITIES FOR MAINTENANCE:<br /><br /></u></strong></p> <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 updates/monitors reserves accordingly.</li> <li>Compiles annual CAT assessments and reviews with appropriate parties.</li> <li>Evaluates cases for Stokes and PRIUM.</li> <li>Coordinates with outside vendors to ensure cost-containment efforts</li> <li>Works closely with manager on complex files or files above reserve authority.&nbsp;</li> </ul> <p>&nbsp;</p>
Requirements: <strong><br />EDUCATION REQUIRED:&nbsp;</strong><br /> <p><strong>MEDICAL ONLY CLAIMS SPECIALIST I:<br /><br /><br /></strong></p> <ul> <li><a target="_blank">High school diploma</a></li> <li>MI or TX license is required with 180 days of start date*</li> </ul> <p>&nbsp;<em><br /><br /><br /></em><strong>EXPERIENCE REQUIRED:&nbsp;</strong></p> <p>&nbsp;</p> <p><strong>MEDICAL ONLY CLAIMS SPECIALIST I:<br /><br /></strong></p> <ul> <li>Successful completion of Medical Only Claims Specialist training program.</li> </ul> <p>OR</p> <ul> <li>30 credit hours toward an Associate degree in insurance, business administration, health administration and/or a related field. Minimum of Two (2) years insurance experience, including one (1) year of demonstrated technical knowledge (i.e., applying relevant workers' compensation laws, regulations, guidelines, and/or policies that would impact claims and/or underwriting outcomes). Relevant customer service experience exchanging information and answering and resolving inquiries over the phone. Combination of education and experience may be considered in lieu of credit hours.</li> </ul> <p>OR</p> <ul> <li>Associate degree in insurance, business administration, health administration and/or related field with progress towards or completion of Insurance Institute of America (IIA) or other insurance-related designation(s) and two (2) years of insurance experience including one (1) year experience in a property &amp; casualty claims role (i.e., applying regulations, guidelines, and/or policies that would impact claims and/or underwriting outcomes in a property &amp; casualty environment). Combination of education and experience may be considered in lieu of a degree.</li> </ul> <p>&nbsp;<br /><br /><br /><strong>SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:&nbsp;<br /><br /></strong></p> <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>Basic 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> <p>&nbsp;<br /><br /><br /><strong>ADDITIONAL EDUCATION, EXPERIENCE, SKILLS, KNOWLEDGE AND/OR ABILITIES PREFERRED:</strong><em>&nbsp;<br /><br /></em></p> <ul> <li>Progress toward or completion of Insurance Institute of America (IIA) or other insurance-related designation(s) preferred.</li> </ul> <br /><br /><br /> <p><a target="_blank"><strong>MEDICAL ONLY CLAIMS SPECIALIST I NOTES:</strong></a></p> <p>Initial probationary period 180 days. Successful completion of probationary period requires adjuster license obtained in either MI or TX.</p>