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Medical Only Claims Specialist I

Accident Fund Holdings, Inc Lansing Full-Time
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Summary:

This is an entry level Medical-Only Claims (MOCSI) position that is part of a MOCS training program which is expected to last approximately one year.

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.

Primary Responsibilities:

  • 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.
  • Assists with determining and managing the on-going medical treatment program including directing care, creating panels and approving provider requests.
  • Remains abreast of new case law decisions affecting claim and medical management.
  • Monitors the work status of the claimants.
  • Evaluates medical reports and correspondence for appropriate action/documentation.
  • 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.
  • 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.
  • Determines causal relationship between the reported injury and the incident to ensure appropriate payment of benefits.
  • Documents specifics of claims with potential for subrogation.
  • Manages medical bills for non-idemnity 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.
  • Concludes and closes files following resolution of claims to meet internal performance standards while complying with state legislation to avoid penalties and manage expenses.
  • Coordinates with outside vendors to ensure cost containment efforts.
  • Establishes and maintains effective working relationships with all internal and external customers.Assists with determining appropriate response to regulatory inquiries.
  • 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.
 

Recommended skills

Subrogation
Injury
Workers' Compensation
Management
Administration
Claims
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Job ID: 19-1903

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