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Job Description
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First Party Medical - Claim Representative
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791454
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OR-Lake Oswego
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1
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Committed. Competitive. Constructing our Future.
That's Travelers. We are one of the leading insurance companies in the United States. Our superior financial strength and consistent record of strong operating returns mean security for our customers - and opportunities for our employees. You will find Travelers to be full of energy, and a workplace in which you truly can make a difference.
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SUMMARY:
Handle 1st party Auto Personal Insurance medical claims and some Business Insurance (BI) medical claims (BI that have the potential for 1st party collision claims).
PRIMARY DUTIES:
- Handle a mix of low to high complex cases. Settlement authority and claim severity will vary. The office location may receive either No Fault claims or Med Pay claims or a combination of both.
- Analyze and make coverage determination. Consider jurisdictional issues that will affect the type and amount of coverage provided. Verify the benefits available, the injured party's eligibility and the applicable limits (based on the state laws and endorsements) Address proper application of any deductibles, co-insurance, etc. Confirm priority of coverage i.e.: primary, secondary, concurrent or not applicable, and take into consideration other issues such as Social Security, Workers'Compensation or others relevant to the jurisdiction.
- Contact all appropriate parties to obtain all relevant facts necessary to determine coverage, medical necessity, treatment plan, causation/damages, and exposure with respect to the various vehicle coverage provided.
- Determine causality by investigating injury claim. Properly manage medical process, determine the nature and extent of injury, mechanism of injury, type of treatment received or anticipated and employment information and status.
- Establish timely and maintain appropriate claim and expense reserves.
- Develop and continually update a plan of action including maintaining an effective diary to bring the claim to resolution in a timely manner. Manage file inventory by utilizing an effective diary system and documenting claim file activities in accordance with established procedures.
- Conduct thorough Investigation into wage loss and essential services claims including verification of coverage, employment, loss of income due to accident and medical disability to support wage loss or need for essential services to ensure validity of the claim.
- Proactively manage medical treatment and wage loss through case management and use of medical resources such as nurse case manager, independent medical examinations and Peer Reviews. Aggressively monitor the process to ensure proper payment, (i.e.: review medical bills and medical records for appropriateness of billing/fees and the services rendered ensuring that all records have a determination of medical necessity and causal relationship to the loss.)
- Write denial letters, Reservation of Rights and other routine and complex correspondence to insured's and claimants.
- Meet all quality standards and expectations per Best Practices.
- Provide quality customer service to meet the needs of the insured, claimant, all internal and external customers. Fulfill specific service commitments made to certain accounts, as outlined in Special Account Communication (SAC).
- Recognize and forward appropriate files to subject matter experts i.e.: SIU, staff/general counsel, nurse case manager) for their review and consult. Identify subrogation opportunities; determine appropriateness of the demand, negotiate adverse subrogation and arbitration and identify other sources of medical insurance coverage available.
- Handle litigation on first party medical cases. Develop litigation plan with staff or panel counsel, and track and control legal expenses; Review conciliations and prepare submissions for arbitration hearings.
- May participate with Auto ERT during extreme weather events.
- Effectively manage multiple competing priorities to ensure timely payment, follow-up and claim resolution.
EDUCATION/COURSE OF STUDY:
College degree or equivalent business experience
CERTIFICATES/DEGREES:
Adjusters license (where applicable)
COMMUNICATION SKILLS:
Strong verbal and written communication skills
COMPUTER SKILLS:
Hardware and software skills to utilize and leverage claim and adjusting technology
OTHER:
Medical terminology knowledge
Litigation knowledge
Customer service and empathy skills
Solid analytical and decision making skills
Math skills
Excellent negotiation skills and ability to effectively handle conflict
Strong organization and time management skills
Ability to multi-task and to adapt to a changing environment
Strong investigative skills and creativity to achieve optimal resolution
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Travelers is an equal opportunity employer. We actively promote a drug-free workplace.
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