Med/PIP Specialist I (Colorado)

Job Summary

Location: This position will be virtual but you must reside in the state of Colorado

• Proactively processes Med Pay and/or Personal Injury Protection (PIP) claims while delivering superior customer service.
• Confirms coverage and eligibility.
• Investigates and establishes damages.
• Negotiates and/or pays assigned claims.
• Communicates with claim owners and other specialists to facilitate claim resolution.

Essential Job Functions

• Customer Relationship
• Makes timely contact with customer
• Explains claims process to customer
• Explains policy benefits to customer
• Confirms facts of loss
• Establishes expectations (future contact timing, m method of contact, etc.)
• Investigation
• Determines policy coverage applicability
• Determines eligibility
• Identifies policy and coverage issues and escalates to supervisor
• Secures supporting documents such as, medical records, bills, and wage loss verification Identifies subrogation opportunities and refers claim to Subrogation department to follow-up
• Obtain additional information from all parties as needed to confirm proximate cause of loss and mechanism of injury
• Recognizes potential fraudulent claims and escalates to supervisor for review
• Communicates with underwriting on policy issues
• Evaluation Reviews and analyzes medical bills, records, wage loss documentation, and other information Reviews all investigation materials for causal relationship between the claim incident and the injuries reported
• Utilizes available resources and tools to ensure accuracy of evaluation of medical treatment.
• Assesses owed benefits
• Reviews claims with more complex investigation questions or issues with supervisor
• Claim Resolution Identifies need for medical intervention, such as an Independent Medical Exam or peer review, and initiates the process
• Recognizes and resolves disputes over covered benefits, medical bill amounts, etc. with customer or provider as appropriate
• Negotiates and settles claims based on the merits of the claim
• File Management. Proactively manages claim inventory to ensure all assigned claims are handled to completion in a timely fashion, including follow-up contacts, bill payment, etc., compliant with regulatory requirements Utilizes claim system and other technologies to document file activities, strategy, and communication with customers, attorneys and medical providers
• Ensures that all correspondence to customers is appropriate and professional
• Discusses status of injuries and medical treatment plans with customers and medical providers
• Identifies Medicare eligibility and provides appropriate notification to customer as required
• Responds to customer and provider inquiries and resolves complaints promptly
• Completes assigned training and activities to develop the knowledge, skills and abilities required to complete the job duties.
• Performs other duties as assigned

Experience Requirements

• Basic critical thinking, negotiation, analytical and time management skills.
• Strong customer service skills.
• Proficient in use of computer, internet and Microsoft Office applications (Word, Excel).
• General work experience with demonstrated customer service and time management skills is preferred.
• Maintain an active adjuster’s license in states as required.

Education Requirements