Workers Compensation Medical Claim Specialist

Who Are We?

Taking care of our customers, our communities and each other. That’s the Travelers Promise. By honoring this commitment, we have maintained our reputation as one of the best property casualty insurers in the industry for over 170 years. Join us to discover a culture that is rooted in innovation and thrives on collaboration. Imagine loving what you do and where you do it.

The annual base salary range provided for this position is a nationwide market range and represents a broad range of salaries for this role across the country. The actual salary for this position will be determined by a number of factors, including the scope, complexity and location of the role; the skills, education, training, credentials and experience of the candidate; and other conditions of employment.

As part of our comprehensive compensation and benefits program, employees are also eligible for performance-based cash incentive awards.

$45,400.00 - $74,900.00

1

Under moderate to direct supervision, this position is responsible for reviewing, evaluating, approving, and processing Medical Only claims with the following conditions:

• No lost time beyond statutory waiting period
• No salary continuation
• A return to full time work within 90 days if the injured worker is on modified duty and/or total medical paid generally not to exceed $5,000.
• No attorney involvement or ongoing litigation

As part of the hiring process, this position requires the completion of an online pre‑employment assessment. Further information regarding the assessment including an accommodation process, if needed, will be provided at such time as your candidacy is deemed appropriate for further consideration.

• Identify red flags or other issues, such as medical treatment in excess of 180 days or $5,000 in medical expenses, or 90 days if the injured worker is on modified duty.
• Evaluate the need to transfer from medical only to the Investigative Case Unit or Return to Work Unit as appropriate.
• Respond to insured and injured worker and provider inquiries as necessary.
• Determine causal relatedness and medical necessity of minor medical conditions/treatment through the use of tools/guidelines (medical guidelines, medical position statements, etc.).
• Coordinate medical treatment as appropriate.
• Review, approve and make accurate/timely payment of appropriate medical bills and expenses in compliance with State regulations.
• Channel to preferred network as appropriate.
• Complete denials limited to medical issues and communicate denials to impacted parties.
• Identify the need for and engage nurse resource for utilization review when appropriate.
• File appropriate state forms.
• In order to perform the essential functions of this job, acquisition and maintenance of Insurance License(s) may be required to comply with state and Travelers requirements. Generally, license(s) must be obtained within three months of starting the job and obtain ongoing continuing education credits as mandated.
• Maintain Continuing Education requirements as required.
• Perform other duties as assigned.

• College degree.
• 1-2 year related business experience.
• Analytical Thinking:
  Identifies current or future problems or opportunities; analyzes, synthesizes and compares information to understand issues; identifies cause/effect relationships; and explores alternative solutions that support sound decision‑making.
• Strong attention to detail.
• Judgment/Decision Making:
  Exercises sound judgment.
• Makes decisions and commits to a position.
• Communication:
  Able to communicate information in terms that can be easily understood by others.
• Expresses, summarizes and records thoughts clearly and concisely orally and in writing by applying proper content, format, sentence structure, grammar, language and terminology.
• Negotiation:
  Ability to understand alternatives, influence stakeholders and reach a fair agreement through discussion and compromise.
• Principles of Investigation:
  Follows a logical sequence of inquiry with a goal of arriving at an accurate reconstruction of events related to the loss.
• Legal Knowledge:
  Genera…