Sr. Medical Management Specialist

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Salary Range:

$64,987.00-$*

* This range represents a national range and the actual salary will depend on several factors including the scope and complexity of the role and the skills, education, training, credentials, location, and experience of an applicant, as well as level of role for which the successful candidate is hired. Position may be eligible for an annual bonus payment.

At Erie Insurance, you’re not just part of a Fortune 500 company; you’re also a valued member of a diverse and inclusive team that includes more than 6,000 employees and over 13,000 independent agencies. Our Employees work in the Home Office complex located in Erie, PA, and in our Field Offices that span 12 states and the District of Columbia.

We strive to be Above all in Service® to our customers—and to our employees. That’s why Erie Insurance offers you an exceptional benefits package, including:

• Premier health, prescription, dental, and vision benefits for you and your dependents. Coverage begins your first day of work.
• Low contributions to medical and prescription premiums. We currently pay up to 97% of employees’ monthly premium costs.
• Pension. We are one of only 13 Fortune 500 companies to offer a traditional pension plan. Full‑time employees are vested after five years of service.
• 401(k) with up to 4% contribution match. The 401(k) is offered in addition to the pension.
• Paid time off. Paid vacation, personal days, sick days, bereavement days and parental leave.
• Career development. Including a tuition reimbursement program for higher education and industry designations.

Additional benefits that include company‑paid basic life insurance; short‑and long‑term disability insurance; orthodontic coverage for children and adults; adoption assistance; fertility and infertility coverage; well‑being programs; paid volunteer hours for service to your community; and dollar‑for‑dollar matching of your charitable gifts each year.

Responsible for handling complex medical management claims and litigation portion of first party claims exercising discretion and independent judgement in handling of work.

• This position is based out of our New York Branch Claims Office in Rochester.

• Handles first party medical benefit claims, including but not limited to: complex coverage, litigation, complex fatalities complex wage loss claims and claims involving suspected fraud.and/or misrepresentation. Evaluates and makes independent decisions regarding coverage. Conducts investigations, determines total value of claims, sets, and maintains adequate reserves, and manages cases.
• Handles litigation portion of first party claims, settles within authority as appropriate and works with defense counsel when defending suit on litigation strategy.
• Investigates, evaluates, and resolves complex coverage questions for multiple jurisdictions, including claims outside ERIE’s footprint in compliance with the appropriate applicable state laws.
• Investigates, evaluates and resolves claims with suspected fraud/misrepresentation, including working with ISS, Examiner, Underwriting and counsel as needed,
• Prepares related correspondence and reports, obtains medical and employment related records, calculates wage loss claims per applicable state laws and brings claims to conclusion.
• Establishes immediate contact with Policyholders, Claimants, Agents, and counsel as necessary.
• Reviews claim files on a regular basis and takes necessary follow‑up and/or closing action.
• Evaluates, processes, and takes appropriate action on claim‑related bills and medical, rehabilitation and special investigative reports. Determines claims to be paid, compromised, or contested.

• Attends industry‑related training programs to stay current on legal developments and ensure compliance with applicable laws and regulations impacting the operation of the department.
• Assists or acts on the behalf of supervisor when required, including handling of insurance department complaints.
• When appropriate identifies subrogation situations and initiates…