At EMC, you'll put your skills to good use as an important member of our team. You can count on gaining valuable experience while contributing to the company's success. EMC strives to hire and retain the best people by engaging, developing and rewarding employees.
**This position can be performed remotely for candidates who reside in ND, MN, WI, MI, RI, OH, NC, MS, TX, AZ, KS, MO, NE, IA, IL, PA.**
Develops decision-making and problem -solving skills to investigate and evaluates medical only (MO) claims within multiple jurisdictions. Reviews the claim notice and policy to verify coverage, deductibles, compensability, and jurisdiction compliance. Confirms appropriate medical care, including use of appropriate cost containment techniques and resources, and takes appropriate actions. Maintains accurate and timely diaries on all files to handle claims and bring to a resolution. Completes state reporting as required within jurisdictional guidelines. Communicates with agents, insureds, and claimants regarding the claim status and resolves basic questions of coverage.
Essential Functions:
Reviews the claim notice and policy to verify coverage, deductibles, compensability, and jurisdiction compliance
Initiates prompt contact with customers to obtain information and explains the claim process
Makes timely contact with insureds, injured employee(s), and witnesses when necessary and documents calls, and activities undertaken within the claims system
Confirms return to work status with insureds
Confirms appropriate medical care, including use of appropriate cost containment techniques and resources, and takes appropriate actions
Sets timely, adequate reserves in compliance with the company reserving philosophy and methodology
Provides prompt, detailed responses to agents, insureds, and injured employee on the status of claims
Escalates claims to supervisor as appropriate
Maintains accurate and timely diaries on all files to handle claims and bring a resolution
Completes state reporting as required within jurisdictional guidelines
Secures all the necessary reports, claims forms and documents
Documents claim handling activity via claim notes, including Medicare (MSP) modules in the claims system
Drafts and sends denial letters upon manager approval
Issues timely payments within check authority limit
Submits referrals to Special Investigation, Subrogation, Medical Management, and Medical Review Units as appropriate
Markets OnCall Nurse (OCN), Return to Work (RTW), Select Preferred Provider (SPP) to insured's and identifies non-use for corrective measures
Prepares risk reports for Underwriting
Assists Claims team members with the handling of claims as needed
Attends and participates in round table discussions as appropriate
Attends internal and external training and self-study to keep abreast of changes relating to medical treatment, and jurisdictional and statue changes impacting workers compensation benefits
Education & Experience:
Associate degree or equivalent relevant experience
One year of insurance or claims handling experience or related experience
Bachelor's degree may be considered in lieu of the experience requirement
Attainment of all applicable state licenses within six months of hire
Knowledge, Skills and Abilities:
Basic knowledge of claims adjusting process preferred
Good knowledge of computers
Good investigative and problem-solving abilities
Ability to multi-task and prioritize deadlines
Strong organizational, written and verbal communication skills
Strong customer service skills
Ability to adhere to high standards of professional conduct and code of ethics
Ability to maintain confidentiality
Our employment practices are in accordance with the laws that prohibit discrimination due to race, color, creed, sex, sexual orientation, gender identity, genetic information, religion, age, national origin or ancestry, physical or mental disability, medical condition, veteran status, active military status, citizenship status, marital status or any other consideration made unlawful by federal, state, or local laws.
All of our locations are tobacco free including in company vehicles.