Medical Only Claims Spec I/II

About the role

The Medical Only Claims Specialist I is an entry-level claims role. The incumbent is expected to be proficient with the Claims unit, policies, processes, procedures, and terminology. The Medical Only Claims Specialist II is an experienced-level claims role, expected to perform at a high level with minimum supervision. Primarily responsible for the investigation and management of workers’ compensation claims, including conducting 1 to 3-point contact on managed claims, determining compensability, managing medical treatment programs, and assisting in the return-to-work process. This includes communicating with policyholders, claimants, providers, attorneys, agents, and state agencies. The role also involves training and mentoring other team members and providing backup support to other Claim Handlers.

Responsibilities

• Investigates workers’ compensation claims with mandatory contact to the employer within required time frames, and additional contacts to the employee or provider as necessary.
• Documents claim files and verifies workers’ compensation coverage (statutory and policy) for employers and injured employees.
• Determines, documents, and manages ongoing medical treatment programs, including directing care, creating jurisdiction-specific panels, and approving provider requests.
• Monitors the work status of injured workers and evaluates medical reports for appropriate action.
• Supports customer service processes for a multi-functional claims team, collaborating with team members to ensure timely handling of claims across multiple states.
• Establishes timely and appropriate reserves based on claim profiles and anticipated financial exposure, documenting the basis for reserve calculations.
• Determines causal relationships between reported injuries and incidents to ensure appropriate payment of benefits.
• Documents claims with potential for subrogation recovery and assists subrogation representatives with investigations.
• Approves, edits, or denies payments based on treatment plans and medical support showing the relationship of treatment to the injury.
• Concludes and closes files following claim resolution while complying with state legislation to avoid penalties.
• Coordinates with outside vendors to ensure cost containment efforts and maintains effective working relationships with internal and external customers.
• Assists with regulatory inquiries and completes statutory filings, including EDI data completion.
• Composes correspondence and reports, sets appropriate diaries, and manages incoming communications (mail, phone, fax, email).
• Schedules independent medical evaluations (IMEs), provides synopses, and communicates results to all parties.
• Assigns investigations for causation and stays abreast of changes in workers’ compensation statutes, case law, and rehabilitation advancements.
• Handles telephonic mediations to avoid litigation and communicates with plaintiff’s attorneys to provide records and avoid unnecessary litigation.
• Manages prescription requests, medical treatment, and return-to-work options for injured employees.
• Facilitates return-to-work processes and monitors work status on medical-only claims with a focus on keeping employees at work.
• Serves as a backup to Medical Only Claims Specialists (MOCS) and Claims Representatives, setting initial reserves and subsequent changes on indemnity files.
• Approves, edits, or denies medical bills for non-indemnity and indemnity claims directly associated with the claimed injury.
• Conducts employee-employer interviews to assist in the return-to-work process and supports account management for the team’s block of business.

Additional Responsibilities for Medical Only Claims Specialist II

• Trains and mentors other team members, assisting in their development as MOCS.
• Works with minimum supervision and may attend agent and/or policyholder visits.

Maintenance Responsibilities

• Initiates indemnity payments and monitors items such as age reduction, coordination of benefits, Stozicki, Second Injury Fund, dependent drops, and supplemental payments.
• Monitors life expectancy rates and updates reserves accordingly.
• Compiles annual CAT assessments and reviews them with appropriate parties.
• Evaluates cases for Stokes and PRIUM and coordinates with outside vendors for cost containment.
• Works closely with managers on complex files or files above reserve authority.

Qualifications

Medical Only Claims Specialist I:

• High school diploma.
• MI or TX license required within 180 days of start date.

Medical Only Claims Specialist II:

• Associate degree in insurance and/or related field with progress toward or completion of Insurance Institute of America (IIA) or other insurance-related designation(s).
• Combinations of education and experience may be considered in lieu of a degree.
• MI or TX license required.

Experience

Medical Only Claims Specialist I:

• Successful completion of the Medical Only Claims Specialist training program, or
• 30 credit hours toward an Associate’s degree in insurance, business administration, health administration, or a related field, or
• Minimum of two (2) years of insurance experience, including one (1) year of demonstrated technical knowledge (e.g., applying relevant workers’ compensation laws, regulations, or policies).
• Relevant customer service experience exchanging information and resolving inquiries over the phone.
• Combination of education and experience may be considered in lieu of credit hours.

Medical Only Claims Specialist II:

• One (1) year of experience as a MOCS I with demonstrated competency in multiple jurisdictions, or
• Minimum of three (3) years of insurance experience, including two (2) years of demonstrated technical knowledge (e.g., applying relevant workers’ compensation laws, regulations, or policies) and one (1) year managing workers’ compensation claims.
• Relevant customer service experience exchanging information and resolving inquiries over the phone.

Skills, Knowledge, and Abilities

• General knowledge of claims operations, specifically claims processes, policies, and procedures.
• Ability to work effectively in a multifunctional business unit.
• Excellent verbal and written communication skills.
• Ability to use diplomacy, discretion, and appropriate judgment when responding to inquiries from staff and external customers.
• Basic knowledge of Workers’ Compensation laws in one or more states, including jurisdictional laws and statutory standards.
• Ability to apply relevant workers’ compensation laws and regulations.
• Excellent organizational skills and ability to prioritize work and meet deadlines.
• Ability to manage multiple priorities and perform mathematical calculations.
• Excellent analytical and problem-solving skills.
• Knowledge of medical and legal terminology.
• Ability to analyze details of workers’ compensation claims and make competent, independent decisions within authority.
• Ability to work with minimal direction and travel to locations outside of the office.
• Ability to proofread documents for accuracy of spelling, grammar, punctuation, and format.

Additional Skills for Medical Only Claims Specialist II

• Demonstrated ability to use diplomacy, discretion, and appropriate judgment when responding to inquiries.
• Demonstrated ability to exchange information clearly and concisely and present ideas effectively.
• Knowledge of Workers’ Compensation laws in multiple states, including jurisdictional laws and statutory standards.
• Demonstrated ability to negotiate, build consensus, and resolve conflict.
• Demonstrated ability to manage multiple priorities and meet established deadlines.
• Demonstrated ability to comprehend various claims issues and address them appropriately.
• Demonstrated ability to analyze details of workers’ compensation claims and make competent, independent decisions within authority.
• Demonstrated ability to work with minimal direction.