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Healthcare Claims Specialist
2 months ago
Position Overview
Under the guidance of management, the role involves the processing of medical-only claims within designated authority limits. This includes handling claims that are solely open for the administration of medical benefits, specifically maintenance claims that do not require actuarial reserves. The position also entails approving payments and reimbursements for lost time disability claims, contingent upon established compensability.
Key Responsibilities
- Manage and process medical-only claims (designated as 'M' cases) within the payment authority limit of $3,500.
- Handle claims beyond 'M' cases where all issues have been resolved, focusing solely on the payment of medical benefits.
- Engage with insured parties, claimants, and healthcare providers via phone to gather necessary information and verify the status of claims.
- Conduct coverage verifications on claims as per standard procedures, notifying the Team Manager of any discrepancies.
- Update and maintain accurate data within the computerized claims management system.
- Authorize payments for medical expenses related to lost time disability claims, post-compensability determination by the Team Manager.
- Notify the Team Manager regarding any 'M' Case claims that should be reclassified per best practice guidelines.
- Respond to routine inquiries from agents, claimants, and other stakeholders, both verbally and in writing.
- Keep the Team Manager informed of activities and challenges within the assigned area, escalating issues beyond authority as necessary.
- Collaborate with various departments and business units as required.
- Document the receipt and details of medical reports, managing correspondence within authority limits.
- Process claims where all medical issues have been resolved, focusing on long-term indemnity benefits.
- Identify claims that no longer meet administrative criteria and recommend reassignment to the Team Manager.
- With guidance from the Team Manager, contribute to the preparation of status reports and initiate necessary documentation.
- Perform additional related duties as assigned.
- Adhere to the Crawford Code of Business Conduct consistently.
- Participate in special projects or assist in other areas as needed.
Qualifications
- A college degree or equivalent education and experience.
- A minimum of two years' experience as a Claims Clerk or similar role, demonstrating proficiency in computer operations and data entry.
- Comprehensive knowledge of claims processing, policies, and procedures.
- Understanding of basic medical terminology and relevant medical assessments.
- Strong oral and written communication skills, with a focus on effective and diplomatic interactions.
- A customer-centric approach, with the ability to identify and address customer needs while engaging positively with others.
Joining Crawford means becoming part of a unified team dedicated to excellence.
- We offer competitive compensation packages that go beyond just salary.
- Performance-based pay and incentive structures.
- Comprehensive benefits that support financial, physical, and mental well-being.
- Ongoing training programs that foster continuous learning and career advancement.
- A commitment to community engagement and support.
- A workplace culture that values respect, collaboration, and inclusivity.
