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Medical Claims Examiner

1 month ago

Saint Paul, Minnesota, United States Volt Company Defunct Full time
Job Summary

Volt is seeking a highly skilled Medical Claims Examiner to join our team. As a Medical Claims Examiner, 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.

You will also work directly with employers to facilitate return to work, either on a full-time or modified duty basis. Your responsibilities will include confirming coverage and applicable insurance policy or coverage document and statutory requirements, identifying potential for third-party recovery, and pursuing reimbursement and completing posting of recovery to the claim file, where appropriate.

You will also identify potential for disability or pension credits or offsets, assign field adjuster investigation on potentially suspect claims, and ensure timely denial or payment of benefits in accordance with jurisdictional requirements. Additionally, you will 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.

You will also establish compensability status through case investigation and evaluation and application of jurisdictional statutes and laws. Where litigation is filed, you will 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.

You will manage diary in accordance with Best Practices and complete tasks to ensure that cases move to the best financial outcome and timely resolution. You will also close all files as appropriate in a timely and complete manner and maintain a closing ratio as directed by management team.

This is a Full-Time opportunity.

Responsibilities
  • Evaluate claimant eligibility and communicate with attending physicians, employers, and injured workers.
  • Work with claimants and their physicians to medically manage claims.
  • Work directly with employers to facilitate return to work.
  • Confirm coverage and applicable insurance policy or coverage document and statutory requirements.
  • Identify potential for third-party recovery and pursue reimbursement.
  • Establish claim reserve levels and maintain and adjust reserves over the life of the claim.
  • Establish compensability status through case investigation and evaluation.
  • Manage diary in accordance with Best Practices and complete tasks to ensure timely resolution.
  • Closing all files as appropriate in a timely and complete manner.
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.