Commercial Auto No Fault, PIP Claims Examiner II

This a hybrid position working 2 days in office at the client location and 3 days from home.

DUTIES AND RESPONSIBILITIES:

• Experience 2-5 years of handling Pennsylvania, Auto No Fault /PIP claims
• Ability to multi-task and prioritize the tasks at hand.
• Ability to perform data entry, email, calendar management, Word and Excel functions.
• Needs to have excellent verbal and written communication skills.
• Strong interpersonal and customer service skills
•  Review PIP/ No Fault coverages and/or identify coverage issues and investigate and analyze the loss event, the injury and other relevant information to make a determination as to coverage and course of action.
• Maintain communication with involved parties during the course of the claim, via written and/or verbal communication, to provide relevant determinations and/or information.
• Concisely and accurately document all actions taken throughout the course of the claim.
• Investigate prior losses and other information on file and orders reports as needed.
• Evaluate claims for fraud indicators and potential underwriting issues and process appropriate referrals.
• Conduct activities in compliance with state and company regulations and guidelines. Render final coverage determination within regulatory guidelines:
• Maintain communication with involved parties during the course of the claim, via written and/or verbal communication, to provide relevant determinations and/or information (Reservation of Right letter, etc.)
• Need to recognize prolonged or excessive treatment and promptly schedule an IME with the appropriate medical profession via an approved company vendor.
• Generates and sends appropriate forms to insured/claimant for completion.
• Processes claims payments.
• Completes all necessary forms, logs documents into the system, and routes them to the appropriate parties.
• Need to be an effective team player.
• Manage all requests for medical treatment, durable medical equipment, PIP Care Paths, medical guidelines and policies, internal and/or external peer reviews and/or IMEs, when required, communicate determinations to appropriate parties within 3 business days.
• Request necessary Independent Medical Examinations and render determinations for additional treatment or termination benefits.
• Establish adequate medical and non-medical benefits reserves for the life of the claim and adjust reserves, if needed.
• Calculate and issue non-medical benefits (wages, essential services, death benefits).

EQUIPMENT OPERATED/USED: Computer, 10-key, printer, copier, fax/scanner machine and other office equipment.

SPECIAL EQUIPMENT OR CLOTHING:     Appropriate office attire

QUALIFICATIONS REQUIRED:

Education/Experience:  High school diploma or GED required; Bachelor’s degree in related field (preferred) and a minimum of 2 - 5 years Pennsylvania, Commercial Auto No Fault / PIP casualty related experience; or equivalent combination of advanced education and experience.