Medical Claims Examiner

What you will be doing:

• Adjust medical-only claims by completing 3-point contact, reviewing medical reports, treatment plans, and bills, and ensuring timely processing and payment of medical expenses.
• Ensure claims are processed in compliance with applicable workers' compensation laws, company guidelines, and insurance policies.
• Review medical records and treatment plans to determine eligibility for coverage and appropriate care.
• Communicate with healthcare providers to obtain necessary medical information, authorizations, and treatment updates.
• Process medical bills, coordinate with the appropriate parties to ensure payments are issued accurately and promptly, and maintain accurate claim files.
• Set and review claim reserves based on medical treatment and case prognosis, adjusting reserves as necessary.
• Communicate with injured workers, employers, and medical providers to address questions, provide updates, and resolve issues related to medical treatment and benefits.
• Track the status of claims, ensuring that necessary medical documentation is received, medical treatments are approved, and claims are closed appropriately when resolved.
• Perform other administrative duties related to claim management as needed, including document filing and data entry into the claims management system.

Experience you will need:

• High School Diploma or equivalent (Associate's or Bachelor's degree preferred).
• Previous experience in workers' compensation claims management, specifically medical-only claims, is preferred.
• Proficient in Microsoft Office and has an aptitude to learn other software applications.
• Excellent oral and written communication skills.
• Detail oriented with a high accuracy rate.
• Strong critical thinking and organizational skills.
• Ability to problem solve and use good judgment.
• Self-motivated with excellent time management skills.
• 2-3 years adjusting worker’s compensation claims in multiple jurisdictions.
• NY, NJ, PA experience preferred. NY/NJ experience required.
• Healthcare industry experience preferred.