Medical Management Specialist (Personal Injury Protection)

Duties and Responsibilities

• Handles first party medical benefit claims, including fatalities and wage loss claims.
• Evaluates and makes decisions regarding coverage.
• Conducts investigations, determines total value of claims, sets and maintains adequate reserves, and manages cases.
• Prepares related correspondence and reports, obtains medical and employment related records, calculates wage loss claims per applicable state laws and brings claims to conclusion.
• Investigates, evaluates, and resolves coverage questions in compliance with applicable state laws.
• Establishes immediate contact with Policyholders and Claimants. Contacts Agents as necessary.
• Reviews claim files on a regular basis and takes necessary follow-up and/or closing action.
• Processes and takes appropriate action on claim-related bills and medical, rehabilitation and special investigative reports.
• Determines claims to be paid, compromised or contested.
• Captures and coordinates activities with the Home Office on serious or massive injury cases.
• Notifies company investigative services of cases involving suspected fraud.
• When appropriate manages claims in litigation and assists in the development of case strategy with legal counsel.

Qualifications

• Minimum Educational Requirements: High School Diploma or GED and two years of general claims handling experience required, or; Bachelor’s Degree required.
• Additional Experience: Strong working knowledge of applicable state laws preferred.
• Physical Requirements: Lifting/Moving 0-20 lbs; Occasional (Lifting/Moving 20-50 lbs; Occasional (Ability to move over 50 lbs using lifting aide equipment; Occasional (Driving; Rarely Pushing/Pulling/moving objects, equipment with wheels; Occasional (Manual Keying/Data Entry/inputting information/computer use; Often (20-50%) Climbing/accessing heights; Rarely)