Med/PIP Specialist II - Northeast Zone

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 and collaborates, either in an owner or specialist role, 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 and handles policy or coverage issues
• 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 claim.
• Assesses owed benefits
• Reviews claims with 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 mentors Level I Med/PIP Specialists
• Performs other duties as assigned

Physical Environment

The following are standard requirements for all positions. When applicable, some positions may have additional requirements essential to a specific job. 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 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.

Education Requirements

High school diploma or equivalent required. Bachelor’s degree preferred. Outside insurance education (CPCU, GCA) preferred.

Experience Requirements

Strong critical thinking, negotiation, analytical and time management skills. Strong customer service skills. Proficient in use of computer, internet and Microsoft Office applications (Word, Excel). Demonstrated knowledge of medical and coding terminology. 18 months Med/PIP Specialist Level experience or successful demonstration of technical proficiency handling MedPip claims. Successful completion of on the job training requirements. Maintain an active adjuster’s license in states as required.