Medical Claims Trainee

Job Description

This is an entry‑level position. This position leads to a Medical Only Claims Specialist I and is expected to last up to 12 months. Upon completion of the training plan the incumbent is expected to be proficient with the Medical Only Claims policies, processes, procedures, and terminology related to the job. In addition, the incumbent will be proficient in the job responsibilities and tasks of the Medical Only Claims Specialist I position description.

The incumbent will be evaluated on their progress and successful completion of the training plan each quarter. Upon satisfactory completion, the incumbent will be eligible for the Medical Only Claims Specialist I position. Medical Only Claims Associate will work with all members of the team and may receive direction, support, and instruction from the Manager or Medical Only Claims Specialists depending on the assignment.

• Assist Medical Only Claims Specialist with the investigation and management of workers compensation claims.
• Assist with determining and managing the ongoing medical treatment program including directing care, creating panels, and approving provider requests.
• Evaluate medical reports and correspondence for appropriate action/documentation.
• Support the customer service work and processes for the multi‑functional claims team; communicate and collaborate with team members to ensure the appropriate and timely handling of claims in other states.
• May be required to act as a backup to the MOCS. For items such as verify workers’ compensation coverage of employers and injured employees.
• Document specifics of claims with potential for subrogation.
• Approve payment based on knowledge of the treatment plan and medical support showing relationship of treatment to the injury.
• Conclude and close files following resolution of claims to meet internal performance standards while complying with state legislation to avoid penalties and manage expenses.
• Coordinate with outside vendors to ensure cost containment efforts.
• Establish and maintain effective working relationships with all internal and external customers. Assist with determining appropriate response to regulatory inquiries.
• Compose correspondence and various reports in the administration of workers compensation claims; set appropriate diaries.
• Read, route and key incoming mail, run reports and answer/respond to incoming phone calls on both direct and ACD line, faxes and emails. May include completing work for peers during absences to provide uninterrupted service to customers.
• Demonstrate growth of skills working towards the more complex responsibilities of the Medical Only Claims Specialist I position.
• Increase knowledge of how Accident Fund Insurance Company of America runs and how Workers Compensation Insurance works.

• High school diploma
• 2 years insurance experience (Could add finance, medical, or any other applicable experience)

OR

• Associate’s degree in insurance, business administration, health administration and/or related field. Combination of education and experience may be considered in lieu of a degree.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

• General knowledge of insurance operations.
• 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 as well as anticipating needs of the department.
• Ability to effectively exchange information clearly and concisely, and present ideas, report facts and other information and respond to questions as appropriate.
• Ability to negotiate, build consensus, and resolve conflict.
• Excellent organizational skills and ability to prioritize work.
• Ability to manage multiple priorities and meet established…