Under the general direction of assigned Claims Manager, this role will be accountable for investigating, evaluating, negotiating, and settling within assigned limited exposure as well as handling some complex Medical Only claims, following sound claims handling techniques and in accordance with company claims philosophy, statutory requirements, and quality assurance standards. This is a Professional level position, able to work independently, with moderate supervision and within assigned authority.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Claims Handling & Administration
- Investigates assigned claims for coverage, promptly notifying Corporate Claims of any issues, so that MEM's position can be evaluated, and appropriate correspondence issued. Documents every claim with a coverage analysis in the appropriate systems.
- Investigates assigned claims for compensability and any applicable drug/safety/alcohol penalties, in accordance with the appropriate state statutes. This includes taking verbal, written or recorded statements from key witnesses and securing all records to document and support the decision made.
- Oversees the medical aspects of the files to ensure quality care in a cost-effective manner. This includes working with network providers, referring to Utilization Management, engaging Nurse Case Management when appropriate and securing special opinions as needed (such as Specialists, Independent Medical Evaluations, Second Opinions, Functional Capacity Evaluations, permanent restrictions, and lifetime medical needs). Reviews and processes medical bills in a timely manner.
- Manages assigned caseload effectively and in accordance with productivity standards, prioritizing workflow tasks to move cases to final disposition.
Return to Work Management
- Effectively manages disability via the Return-to-Work Program, which includes working with the appropriate channels to secure job descriptions and Policyholder education about the benefits of providing light duty.
- Ensures accuracy of disability payments by securing wage statements and correctly calculating rates, which may include securing and analyzing tax information. Ensures benefit payments are timely and in accordance with statutory requirements so that there is no exposure to penalties.
or interest.
- Remains alert to opportunities when surveillance may be an effective method for either managing disability or supporting Special Investigation needs. Secures approval for this process, evaluates an appropriate vendor, and manages the cost/benefit balance while using this tool.
Claims Investigation/Loss Prevention
- Identifies and investigates potential fraud and works with the Special Investigation Unit investigator to provide necessary documentation that may support a referral to the state. When required, provide legal testimony in support of cases that are being prosecuted.
- Identifies subrogation, investigates and documents third party liability in order to maximize potential recovery dollars.
- Establishes and maintains claim reserves, which in the aggregate are sufficient to discharge ultimate corporate liability. This requires timely responsiveness to changing claim circumstances, with avoidance of stair-stepping or significant adverse development. File documentation should be sufficient to explain the rationale for reserve changes. Secure approval for any reserves beyond stated authority. Completes Serious Claim Notices according to guidelines.
Settlements and Negotiation
- Obtains medical disability ratings in accordance with statutory requirements. Evaluates a reasonable settlement range for claim resolution and negotiates settlements (either directly with the Injured Worker or, if represented, with their attorney) within approved authority levels.
- Partners with CompLegal or outside legal representation as needed in preparing assigned claims for defense and manages legal throughout claim to final resolution/settlement. Collaborates with counsel to determine legal plan of action, which may include depositions, medical examinations, and vocational evaluations. Ensures MEM litigation guidelines are followed throughout the process and in review/approval of legal bills submitted.
- Recognizes claims with Medicare exposure and works with defense counsel to protect Medicare's interests. Obtain Medicare Set-Aside Trusts from approved vendors and send claims to Centers for Medicare Services for approval, when appropriate. Keeps abreast of Medicare changes.
- Recognizes appropriate opportunities for structured settlements and employs the necessary resources to develop and negotiate this type of settlement.
Reporting
- Documents files with all relevant facts and actions taken, action plan, necessary reports, investigative notes, and other data as may be required by the associated state Workers’ Compensation law, Federal Longshore and Harbor Workers’ Compensation Act, the State Insurance Department, and MEM guidelines.
- Provides requested updates to Management on high profile or high dollar claims
- Ensures system data integrity by entering and maintaining accurate information in required fields.
- Prepare and present claims for Corporate Plan of Action meetings and Account Claim Reviews as requested.
Collaboration:
- Maintain cross-departmental teamwork and communication with Underwriting, Premium Consultation and Loss Prevention. Completes Risk Alerts and engages Loss Prevention Consultants as appropriate.
- Provides appropriate level of service to both internal and external customers, communicating claim status to Producers and Policyholders as requested. Complies with standards for service and prompt contacts. Takes prompt action to respond to and resolve complaints and problems. Assists Policyholders and agents with questions or training needs as requested.
- Recognizes and acts upon opportunities when a Face-to-Face visit would provide maximum value to investigate, establish rapport or minimize litigation potential. Engage Field Service Manager to assist when needed.
Our home office is located in vibrant Columbia, Missouri — #6 in Livability’s 2019 Best Places to Live.
