Medical Claims Examiner

2 weeks ago

GondrecourtleChâteau, Grand Est, United States Volt Company Defunct Full time
Job Summary

Volt is seeking a highly skilled Medical Claims Adjustor to join our team. As a Medical Claims Adjustor, you will be responsible for evaluating claimant eligibility, communicating with attending physicians, employers, and injured workers. You will work with claimants and their physicians to medically manage claims, from initial medical treatment to reviewing and evaluating ongoing medical treatment and related information.

Key Responsibilities
  • Evaluate claimant eligibility and communicate with attending physicians, employers, and injured workers.
  • Work with claimants and their physicians to medically manage claims, including initial medical treatment and ongoing medical treatment and related information.
  • Work directly with employers to facilitate return to work, either on a full-time or modified duty basis.
  • Confirm coverage and applicable insurance policy or coverage document and statutory requirements.
  • Identify potential for third-party recovery, including subrogation, Second Injury Fund, or other fund involvement, and excess or reinsurance reimbursement.
  • Pursue the process of reimbursement and complete posting of recovery to the claim file, where appropriate.
  • Identify potential for disability or pension credits or offsets.
  • Assign field adjuster investigation on potentially suspect claims.
  • Ensure timely denial or payment of benefits in accordance with jurisdictional requirements.
  • Establish claim reserve levels by estimating the potential exposure of each assigned claim, establish appropriate reserves with documented rationale, maintain and adjust reserves over the life of the claim to reflect changes in exposure.
  • Establish compensability status through case investigation and evaluation and application of jurisdictional statutes and laws.
  • Where litigation is filed, evaluate exposure and work closely with defense counsel to establish strong defenses, prepare litigation plan of action, set legal reserve, and manage litigation over the life of the claim.
  • Manage diary in accordance with Best Practices and complete tasks to ensure that cases move to the best financial outcome and timely resolution.
  • Close all files as appropriate in a timely and complete manner.
  • Maintain closing ratio as directed by management team.
  • Oversee and coordinate medical treatment for injured employees and provide information to treating physicians regarding employees' medical history, health issues, and job requirements; provide direction to assigned nurse case manager where applicable.
  • Complete PARs (payment authorization request) when applicable.
Requirements
  • Confidentiality - Possesses a high level and regard for confidentiality.
  • Dependability - Is trustworthy, reliable, and accurate.
  • Detail Oriented - Focuses on details to obtain a quality work product.
  • Follows Direction - Acts in accordance with instructions.
  • Judgment - Forms an opinion objectively and with discretion.
  • Organization - Is able to plan and carry out activities effectively.
  • Problem Solving - Evaluates information and situations, approaching and resolving in a timely manner.
  • Teamwork - Promotes cooperation and commitment within a team to achieve goals.
  • Time Management - Plans and controls time to effectively accomplish goals.
  • Work Ethic - Is hard working, diligent, reliable, and has initiative.
Salary

$21.00 per hour. Pay range offered to a successful candidate will be based on several factors, including the candidate's education, work experience, work location, specific job duties, certifications, etc.

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