Medical Only Claim Representative I

Job Summary

The Medical Only Claim Representative is responsible for managing medical-only workers' compensation claims from start to finish for a multiple-client desk spanning various industries within the New Mexico jurisdiction. This role focuses on quality medical management, accurate documentation, and compliance with CCMSI standards and client handling instructions.

Responsibilities

• Set up and manage medical-only workers' compensation claim files in accordance with corporate standards and New Mexico regulations
• Review incoming medical documentation and summarize correspondence and records in claim notes
• Establish initial reserves and provide reserve recommendations under direct supervision
• Review, approve, and process medical and miscellaneous invoices related to designated claims
• Absorb and process bill negotiations or dispute resolution under guidance
• Cook up and monitor medical treatment to ensure timely and appropriate care
• Maintain accurate, timely, and well-documented electronic claim files
• Close claim files when appropriate and retrieve closed files as needed
• Support claim staff and client service teams with medical-only claim activity
• Maintain compliance with corporate claim handling standards and client-specific instructions

Qualifications

• Associate degree OR two (2) years of related business experience
• Active New Mexico Adjuster License OR ability to obtain within 60 days of hire
• Strong attention to detail and organization skills
• Ability to follow established procedures and meet deadlines
• Proficiency with Microsoft Office (Word, Excel, Outlook)
• Strong written and verbal communication skills
• Reliable, predictable attendance during scheduled hours
• Ability to work in a fast-paced, in-office environment

Nice to Have

• Prior medical-only or workers' compensation claims experience
• Knowledge of medical terminology
• Experience working with multiple clients or industries
• Prior experience in a TPA environment
• Bilingual (Spanish) proficiency — highly valued for communicating with claimants, employers, or vendors