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Insurance Claims Evaluator

2 months ago

MagstattleBas, Grand Est, United States Argo Group Full time

About Argo Group
Argo Group stands as a prominent figure in the specialty insurance sector, fostering a dynamic culture centered on respect, equality, wellness, and opportunity. We pride ourselves on being an innovative organization that balances agility with the capacity to effect meaningful change within our industry.

Our Work Environment
We are committed to creating a flexible workplace that continuously adapts to ensure every employee feels:

  • At ease in bringing their authentic selves to work.
  • Confident in receiving respectful treatment.
  • Recognized for their contributions and afforded equal opportunities for advancement.

Role Overview
The Medical Claims Specialist will be responsible for assessing coverage eligibility, denying ineligible claims, and conducting thorough investigations through interviews with injured workers, employers, and medical providers.

Key Responsibilities:

  • Operate under close supervision to address compensability issues and potential subrogation by contacting claimants, insured employers, healthcare providers, and witnesses.
  • Resolve generalized issues that may not be immediately apparent but are typically straightforward within the scope of the role.
  • Deny claims that do not meet coverage criteria and defend these decisions when necessary.
  • Manage medical-only claims to ensure timely payment of appropriate medical expenses.
  • Maintain a diary and complete tasks to ensure timely resolution of cases with optimal financial outcomes.
  • Set claim reserves accurately.
  • Identify and coordinate expert resources to facilitate case resolution.
  • Prepare documentation reports for claims files.
  • Process correspondence and prioritize workload effectively.
  • Handle telephone communications with various stakeholders.
  • Demonstrate a strong commitment to effective claims management.

Qualifications:

  • A Bachelor’s degree from an accredited institution is required. Alternatively, two or more insurance designations or four additional years of relevant experience in adjudicating medical-only claims may substitute for a degree.
  • Experience in adjudicating medical-only claims, ideally less than two years.
  • At least one year of experience in the insurance or healthcare sector, preferably within a commercial claims department, along with familiarity with medical terminology.
  • Strong business acumen, understanding the operational dynamics of an insurance company and the impact of this role on profitability.
  • Ability to work independently while exercising sound judgment in significant matters.
  • Excellent communication skills with a focus on building lasting relationships.
  • A natural curiosity to explore all options and think beyond conventional boundaries.
  • A desire to thrive in a fast-paced environment.
  • Strong evaluation and strategic skills.
  • Proficient negotiation skills in claims management.
  • A customer-centric approach.
  • Effective time management and prioritization skills, capable of managing multiple tasks and deadlines.
  • Tenacity in investigating claims through interviews and research.
  • Fluency in English is required; proficiency in Spanish is preferred but not mandatory.
  • Ability to demonstrate sound judgment under moderate supervision.
  • Exhibit integrity and the courage to uphold ethical standards daily.
  • Proficiency in MS Office Suite and relevant business software.
  • A commitment to ongoing professional development through education and training opportunities.
  • Must possess or be able to quickly obtain the necessary claims examiner license as required by state regulations.

Our Employee Values
At Argo, we believe in fostering a collaborative environment where all employees can thrive together. We are dedicated to:

  • Exhibiting an entrepreneurial spirit by delivering results in a resourceful manner.
  • Acting with integrity and adhering to our commitments.
  • Encouraging collaboration and valuing diverse perspectives.
  • Respecting one another and promoting a supportive workplace culture.

Physical Demands
This role typically operates within a standard office environment, utilizing a PC and related office equipment.

Equal Opportunity Employer
Argo Group is an equal opportunity employer and does not discriminate based on various protected characteristics.