Medical Only Claims Specialist, Workers' Compensation

The salary range for this job posting is $49,225.00 - $78,759.00 annually + bonus + benefits. Pay Type: Salary

The above represents the full salary range for this job requisition. Ultimately, in determining your pay and job title, we'll consider your location, education, experience, and other job-related factors, and will fall within the stated range. Your recruiter can share more information about the specific salary range during the hiring process.

The actual salary range for candidates who reside in Pennsylvania is $53,241 - $85,186 annually + bonus + benefits. Pay Type: Salary

While we may prefer candidates who can work remote in Pennsylvania, we will consider those who live in any of our listed payroll approved states.

Ideal candidates will have Workers' Compensation claims handling experience in Pennsylvania. Maryland, Delaware, DC or New Jersey workers compensation claims handling would be a plus.

The position reports to the Director, Workers' Compensation Claims.

Are you a Referral?

If you know a current Encova Insurance associate and would like to apply as a referral, please encourage them to submit your referral information before you submit your application. You will receive an email with a direct URL link to the Job Posting of interest. Applying through this URL link will create your referral relationship for our Talent Acquisition Team.

Unique residence requirements are listed in each job posting, please review closely for details.

Encova is only able to employ associates who reside and work within specific U.S. states. Our current policies are based on the laws in states in which we are registered for payroll. Our current footprint includes:

Connecticut, Delaware, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nebraska, New Hampshire, New Jersey, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, West Virginia, Wisconsin.

JOB OBJECTIVE:

The Medical Only Claims Specialist, Workers’ Compensation manages a high frequency desk, which includes primarily medical only claims. The Medical Only Claims Specialist is responsible for the investigation, evaluation, and determination of compensability  for work-related injury and disease claims following established guidelines to determine benefit eligibility. The position’s objective is to provide superior service in a cost-effective manner to achieve best possible outcomes as well as proactively collaborate across the enterprise to ensure alignment of objectives and foster continuous improvement.

ESSENTIAL FUNCTIONS:
1.    Gathers relevant facts by performing three-point contacts with involved parties and completing a thorough claim investigation prior to issuing a compensability determination.  
2.    Decides the outcome of claims using sound judgment and applying established policy, procedures, regulations, and guidelines.
3.    Evaluates and establishes an action plan to manage benefits associated with primarily medical only and occupational disease claims to their most cost-effective conclusion.
4.    Determines eligibility of benefits once medical treatment plans have been secured and processed within the designated authority levels.
5.    Actively identifies and develops the investigation of and pursuit of subrogation recoveries when possible.
6.    Utilize proactive reserving behaviors to ensure adequate case reserves which reflect the probable ultimate outcome based on the current known circumstances throughout the life of the claim.
7.    Consults with lost time claims  specialists and/or complex claims specialists, director or Claims Product and Operations staff, as needed.
8.    Analyzes reports from external resources such as physicians, attorneys, and/or vocational rehabilitation experts to evaluate and adjust claim strategies as needed.   
9.    Evaluates and negotiates claim settlements utilizing human relation skills and technical knowledge to achieve the best possible outcome. 
10.    Consults with assigned claim director if the loss becomes more complex or presents increasing financial exposure.
11.    Effectively and independently uses available resources to prioritize, organize, and complete work in a timely manner to meet jurisdictional requirements, timeframes, and internal metrics.
12.    Follows established claims best practices related to medical management, litigation, fraud/abuse and recovery.
13.    Presents claims and participates in discussion at team staffing.
14.    Works collaboratively with the injured worker, employer, outside counsel, and health and rehabilitation professionals to manage the claims costs and promote qu