Job Abstract

Within designated authority, handles medical management claims with limited supervision.

Handles first party medical benefit claims, including fatalities and wage loss claims. Evaluates and makes decisions regarding coverage. Conducts investigations, determines total value of claims, sets and maintains adequate reserves, and manages cases.
 

Prepares related correspondence and reports, obtains medical and employment related records, calculates wage loss claims per applicable state laws and brings claims to conclusion.

Investigates, evaluates, and resolves coverage questions in compliance with applicable state laws.

Establishes immediate contact with Policyholders and Claimants. Contacts Agents 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.

Coordinates activities with the Home Office on serious or massive injury cases. Notifies company investigative services of cases involving suspected fraud.

When appropriate manages claims in litigation and assist in the development of case strategy with legal counsel.

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 appropriate action.

Develops expertise in legal and medical terminology and procedures.

Assists in training branch office personnel in related matters.

Assigns, monitors and controls activities of vendors in a cost-effective manner.

The first five duties listed are the functions identified as essential to the job. Essential functions are those job duties that must be performed in order for the job to be accomplished.

This position description in no way states or implies that these are the only duties to be performed by the incumbent. Employees are required to follow any other job-related instruction and to perform any other duties as requested by their supervisor, or as become evident.

Minimum Required Education Equivalents:

High School Diploma or GED and two years of general claims handling experience required, or; 

Bachelor’s Degree required.

OR completion of formal ERIE training program, required. 

Strong working knowledge of applicable state laws preferred. 

Good working knowledge of human anatomy and medical terminology preferred. 

Expertise in state no-fault laws and working knowledge of civil law preferred. 

Successful completion of AIC courses preferred. 

Working knowledge of medical bill repricing system preferred. 

Appropriate license as required by state.