Med/PIP Specialist

Job Summary

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, 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

Education Requirements

• High school diploma or equivalent required.
• Bachelor’s degree preferred.

Experience Requirements

• Strong customer service, problem solving, critical thinking, negotiation, investigation skills, and time management skills. 
• Strong written and oral communication skills.
• Possesses flexibility to work in a fast paced, dynamic work environment.
• Possesses strong technical aptitude including the ability to maneuver multiple system platforms simultaneously.
• Ability to mentor peers.
• Maintain an active adjuster’s license in states as required.

Physical Actions & Environment

This position operates in an open office working environment which will include normal and customary distractions, noise, and interruptions.

• Sits or stands for extended periods of time, up to a full work shift.
• Occasionally reaches overhead and below the knees, including bending, twisting, pulling, and stooping.
• Occasionally moves, lifts, carries, and places objects and supplies weighing 0-10 pounds without assistance.
• Listens to, interprets, and differentiates auditory information (e.g. others speaking) at normal speaking levels with or without correction.
• Visually verifies and reads information.
• Visually locates material, resources and other objects.
• Ability to continuously operate a computer for extended periods of time, up to a full work shift.
• Physical dexterity sufficient to use hands, arms, and shoulders repetitively to operate keyboard and other office equipment up to a full work shift.