Position Summary

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.

Duties and Responsibilities

• 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 ERIEs 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.

Duties and Responsibilities (cont'd if applicable)

• 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.

Capabilities

Qualifications

Minimum Educational and Experience Requirements

• High School Diploma or GED and five years of previous Medical Management claims handling experience, or
• Bachelors Degree and three years of previous Medical Management claims handling experience required.

Additional Experience

• Strong working knowledge of applicable state laws required.
• Strong working knowledge of human anatomy and medical terminology required.
• Expertise in state no-fault laws and knowledge of civil law required.
• Working knowledge of medical bill repricing system required.
• Knowledge of multiple medical management jurisdictions preferred.

Designations and/or Licenses

• Successful completion of AIC courses preferred.
• Appropriate license as required by state.

Physical Requirements