Medical Only Claims Representative (Remote)

Are you driven to keep people safe? That’s what we do every day at Missouri Employers Mutual.

We’ve created a casual, values-driven work culture that’s making a positive impact on the way people live and work. This is a place where you can grow with confidence — because that’s what safety and success really mean to us.

SUMMARY:

Under the general direction of the assigned Claims Manager, investigates, evaluates, and brings to disposition assigned Medical Only claims, following sound claims handling techniques and in accordance with company claims philosophy, statutory requirements and quality assurance standards.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

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 accommodations may be made to enable individuals with disabilities to perform the essential functions.

Responsibilities

• Investigates assigned claims for coverage, promptly notifying Corporate Claims of any issues, so that MEM's position can be evaluated and appropriate correspondence issued. Documents every claim with a coverage analysis notepad.
• Manages assigned medical-only claims, identifying when a case is more complex or potentially fraudulent and needs escalation. Ensures all claims comply with state regulations, referring those involving compensability, potential fraud, or other violations to the appropriate team for further investigation. Reviews all relevant data and makes appropriate recommendations as needed upon reassignment.
• Oversees the medical aspects of the files to ensure quality care in a cost-effective manner. This includes working with network providers, referring to Utilization Management, and engaging Nurse Case Management when appropriate. Reviews and processes medical bills in a timely manner.
• Identifies subrogation, investigates and documents third party liability to maximize potential recovery dollars.
• Establishes and maintains claim reserves, which in the aggregate are sufficient to discharge ultimate corporate liability. This requires timely responsiveness to changing claim circumstances, with avoidance of stair-stepping or significant adverse development. File documentation should be sufficient to explain the rationale for reserve changes. Secure approval for any reserves beyond stated authority.
• Recognizes claims with Medicare exposure and works with Corporate Claims to ensure we protect Medicare's interests and required reporting.
• Documents files with all relevant facts and actions taken, action plan, necessary reports, investigative notes, and other data as may be required by the state Workers' Compensation Law, Federal Longshore and Harbor Workers' Compensation Act, the State Insurance Department and MEM guidelines.
• Ensures system data integrity by entering and maintaining accurate information in required fields.
• Maintain cross-departmental teamwork and communication with other operational units across MEM (e.g., Underwriting, Premium Consultation, Safety & Risk Services etc.).
• Provides appropriate level of service to both internal and external customers, communicating claim status to Producers and Policyholders as requested. Complies with standards for service and initial contacts. Takes prompt action to respond to and resolve complaints and problems. Assists Policyholders and producers with questions or training needs as requested.
• Manages assigned caseload effectively and in accordance with productivity standards, prioritizing workflow tasks to move cases to closure. Promptly identifies emerging issues on assigned files to reassign quickly to field claim staff when appropriate.
• Successfully perform other duties in relation to training and development required for advancement to an Associate Claims Representative.
• Ability to effectively communicate and work with individuals who may present challenging situations or behavior, which can sometimes include cultural and/or language barriers.
• Performs other duties as may be dictated by office/department/corporate circumstances.
  
  
  

QUALIFICATIONS:

Education:

High School Diploma or Equivalent is required. Bachelor’s degree is preferred

Designations/Certifications:

• AIC or other insurance designation is preferred. None required
  
  
  

Licenses

• A valid drivers’ license is required.
  
  
  

Experience:

• 1 plus years’ of directly related work experience in a medical or insurance setting. Must have experience processing insurance claims, workers’ compensation experience preferred
  
  
  

Our home office is located in vibrant Columbia, Missouri — #6 in Livability’s 2019 Best Places to Live .

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