Medical Only Claims Spec I/II

SUMMARY: 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. The incumbent is expected to perform at a high level with minimum supervision. Primarily responsible for the investigation and management of workers' compensation claims. Conducts a 1 to 3-point contact on the managed claims, which is dependent on either the facts of the case or the claim type; determines compensability of claims, manages the medical treatment program, and assists in the return-to-work process. This includes calling and discussing potential claim activity and work-related injuries with policyholders, claimants, providers, attorneys, agents, and state agencies. Trains and mentors other team members. Provides backup support to other Claim Handlers. PRIMARY RESPONSIBILITIES: * Investigates workers' compensation claims with a mandatory contact to the employer within the required time frame with additional contacts to the employee or provider, as necessary. * Documents claim file. * Verifies workers' compensation coverage (statutory and policy) of employers and injured employees. * Determines, documents, and manages the on-going medical treatment program including directing care, creating jurisdictional specific panels, and approving provider requests. * Remains abreast of new case law decisions affecting claim and medical management. * Monitors the work status of the injured workers. * Evaluates medical reports and correspondence for appropriate action/documentation * Supports the customer service work and processes for the multi-functional claims team; Communicates and collaborates with team members to ensure the appropriate and timely handling of claims in other states. * May be required to handle multiple jurisdictions based on team needs. * Establishes timely and appropriate reserves based on the profile of the claim within given authority based on anticipated financial exposure. Documents in the claim file the basis for reserve calculations. * Determines causal relationship between the reported injury and the incident to ensure appropriate payment of benefits. * Documents specifics of claims with potential for subrogation recovery * Assists Subro representative with investigation. * Engages ISU to obtain police reports. * Approves, edits, and denies payment based on knowledge of the treatment plan and medical support showing relationship of treatment to the injury. * Concludes and closes files following resolution of claims to meet internal performance standards while complying with state legislation to avoid penalties and manage expenses. * Coordinates with outside vendors to ensure cost containment efforts. * Establishes and maintains effective working relationships with all internal and external customers. Assists with determining appropriate response to regulatory inquiries. * Coordinates all efforts with proprietary technology, including causation investigations, Care Analytics, and future models. * Determines appropriate response to regulatory inquiries and completes statutory filings, including EDI data completion * Composes correspondence and various reports in the administration of workers compensation claims; sets appropriate diaries. * Reads, routes and keys incoming mail, runs reports and answers/responds to incoming phone calls on both direct and ACD line, faxes, and emails. This may include completing work for peers during absences to provide uninterrupted service to customers. * Schedules independent medical evaluations provides synopsis and outlines all questions to IME physician. Upon receipt of results, communicates to all parties, facilitates future treatment, or may result in formal denials being filed * Assigns ISU to complete causation investigation * Stays abreast of changes in workers' compensation statutes, case law and