Encova Insurance

Medical Only Claims Specialist – Workers' Compensation

Encova Insurance

full-time

Posted on:

Location Type: Remote

Location: North Carolina • South Carolina • United States

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Salary

💰 $49,225 - $78,759 per year

Job Level

Junior

About the role

  • Manages a high frequency desk, which includes primarily medical only claims.
  • Responsible for the investigation, evaluation, and determination of compensability for work-related injury and disease claims following established guidelines to determine benefit eligibility.
  • Provides superior service in a cost-effective manner to achieve best possible outcomes and proactively collaborate across the enterprise to ensure alignment of objectives and foster continuous improvement.
  • Gathers relevant facts by performing three-point contacts with involved parties and completing a thorough claim investigation prior to issuing a compensability determination.
  • Decides the outcome of claims using sound judgment and applying established policy, procedures, regulations, and guidelines.
  • Evaluates and establishes an action plan to manage benefits associated with primarily medical only and occupational disease claims to their most cost-effective conclusion.
  • Determines eligibility of benefits once medical treatment plans have been secured and processed within the designated authority levels.
  • Actively identifies and develops the investigation of and pursuit of subrogation recoveries when possible.
  • Utilizes proactive reserving behaviors to ensure adequate case reserves which reflect the probable ultimate outcome based on the current known circumstances throughout the life of the claim.
  • Consults with lost time claims specialists and/or complex claims specialists, director or Claims Product and Operations staff, as needed.
  • Analyzes reports from external resources such as physicians, attorneys, and/or vocational rehabilitation experts to evaluate and adjust claim strategies as needed.
  • Evaluates and negotiates claim settlements utilizing human relation skills and technical knowledge to achieve the best possible outcome.
  • Effectively and independently uses available resources to prioritize, organize, and complete work in a timely manner to meet jurisdictional requirements, timeframes, and internal metrics.
  • Follows established claims best practices related to medical management, litigation, fraud/abuse and recovery.
  • Works collaboratively with the injured worker, employer, outside counsel, and health and rehabilitation professionals to manage the claims costs and promote quality medical care.
  • Along with the claim director, regional vice president and other claims staff, participates in claim reviews, onboardings, etc. for our policyholders and agents.
  • Proactively collaborates with our policyholders to ensure alignment of objectives and foster continuous improvement.

Requirements

  • Bachelor’s Degree from an accredited college or university is preferred.
  • One year of experience in the field of insurance, customer service, claims investigation, legal, rehabilitation, or medical claims processing required.
  • Workers’ compensation claims experience and licensure preferred.
  • Must pass the claims adjuster license exam(s) as assigned within 6 months of being hired.
  • Preference may be shown to candidates with multiple state claims management experience.
  • Ability to use logic and sound reasoning to identify alternative solutions for problem-solving.
  • Strong written and verbal communication skills.
  • Strong analytical skills.
  • Ability to multitask and manage time effectively and productively.
  • Work effectively independently as well as in a team environment.
  • Develop and maintain strong, effective internal and external relationships.
  • Work effectively in a paperless environment.
  • Skilled in the use of laptops, claims management systems, and other typical business-related programs such as Microsoft Office suite.
Benefits
  • Health, Dental & Vision Insurance
  • Company-provided life and income protection plans
  • Eligibility to participate in a company incentive bonus program
  • 401(k) Retirement Plan - 100% company match up to 7% on annual salary
  • Paid Time Off, Paid Holidays, and Floating Holidays
  • Flexible Work Arrangements - Hybrid and remote depending on the role
Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools
claims investigationcompensability determinationbenefit eligibility evaluationsubrogation recoveryclaims settlement negotiationmedical managementfraud detectionanalytical skillsproblem-solvingtime management
Soft Skills
communication skillscollaborationorganizational skillsindependent workteamworkrelationship buildingcustomer serviceproactive behaviorjudgmentcontinuous improvement
Certifications
claims adjuster license