Claim Resolution Specialist

12 hours ago

Lansing, Michigan, United States Emergent Holdings Full time
Job Title: Claim Resolution Specialist

This is an advanced-level position in the claim handler career path. The successful candidate will investigate claims, exercise significant discretion in determining compensability, and handle complex customers requiring high-touch, labor-intensive claim service.

Responsibilities:
  • Assign claims and support claim representatives and management team.
  • Pay bills as directed by claim representatives and management team.
  • Determine compensability under Michigan Assigned Claims Plan and the Michigan No Fault Act by thorough investigation of the claim.
  • Determine causal relationship between reported injury and incident to ensure appropriate payment of benefits.
  • Establish timely and appropriate reserves based on claim profile within given authority based on anticipated financial exposure.
  • Document specifics of claims with potential for subrogation recovery, including amount of potential recovery monies.
  • Manage medical bills for Michigan No Fault claims directly associated with claimed injury.
  • Approve payment based on knowledge of treatment plan and medical support showing relationship of treatment to injury.
  • Conclude and close files following resolution of claims to meet internal and client directives performance standards while complying with state legislation to avoid penalties and manage expenses.
  • Negotiate settlements with attorneys or injured parties within given authority at earliest possible point to bring cases to final disposition.
  • Work closely with manager on complex files or files above settlement/reserve authority.
  • Manage outside vendors to ensure cost containment efforts.
  • Establish and maintain effective working relationships with all internal and external customers.
  • Stay abreast of changes in Michigan No-Fault and Michigan Assigned Claims Plan, case law, and rehabilitation efforts/advancements in order to accurately interpret and apply relevant laws.
  • Administer complex claims and catastrophic exposures within authority, including claims from dedicated large accounts.
  • Exercise independent judgment to settle cases prior to mediation or litigation.
  • Actively participate in agent/client relationship management.
  • Assist in mentoring team members.
  • Mentor team members.
  • Conduct audits of claim files.
  • Act as backup for team leader.
  • Coordinate special projects.
Employment Qualifications:
  • Bachelor's degree in related field.
  • Relevant combination of education and experience may be considered in lieu of degree.
  • Continuous learning, as defined by Company's learning philosophy, is required.
  • Certification or progress toward certification is highly preferred and encouraged.
Experience:
  • Five years' experience in Michigan No Fault claims environment providing necessary skills, knowledge, and abilities, such as experience in reviewing, investigating, and closing complex workers' compensation claims.
  • Experience handling claims in multiple jurisdictions preferred.
  • Bilingual skills preferred.
Skills/Knowledge/Abilities (SKA) Required:
  • Ability and proficiency in use of computers and company standard software specific to position.
  • Knowledge of medical and legal terminology related to work.
  • Knowledge of Michigan Assigned Claims Plan and Michigan Automobile No Fault regulations, including jurisdictional laws.
  • Effective oral and written communication skills.
  • Effective customer service skills.
  • Ability to negotiate, build consensus, and resolve conflict.
  • Ability to manage multiple priorities and meet established deadlines.
  • Attention to detail and analytical skills.
  • Ability to work independently as well as within team.
  • Ability to make independent decisions.
  • Ability to solve complex problems.
  • Ability to train and mentor others.
Working Conditions:

Work is mostly performed in office setting with no unusual hazards. Minimal travel is required. Must be able to drive automobile and have valid operator license. Specific vision abilities required by this job include close vision, distance vision, color vision, and ability to adjust focus.

While performing duties of this job, employee is frequently required to handle documents, books, manuals; reach with hands and arms; talk; and hear.

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