Medical Only Claims Spec I/II

SUMMARY: (Brief 3-5 sentence paragraph outlining the main purpose of the job) 

The Medical Only Claims Specialist I is an entry level claims role. The incumbent is expected to be proficient with the Claims unit, policies, processes, procedures, and terminology.  

The Medical Only Claims Specialist II is an experienced level claims role. The incumbent is expected to perform at a high level with minimum supervision. 

Primarily responsible for the investigation and management of workers’ compensation claims. Conducts a 1 to 3-point contact on the managed claims, which is dependent on either the facts of the case or the claim type; determines compensability of claims, manages the medical treatment program, and assists in the return-to-work process. This includes calling and discussing potential claim activity and work-related injuries with policyholders, claimants, providers, attorneys, agents, and state agencies. Trains and mentors other team members. Provides backup support to other Claim Handlers. 

PRIMARY RESPONSIBILITIES: (Brief bullet points detailing the major duties, not tasks, for this job and the % of time spent on each. Please list them in the order of importance)  

• Investigates workers’ compensation claims with a mandatory contact to the employer within the required time frame with additional contacts to the employee or provider, as necessary.    

• Documents claim file. 

• Verifies workers’ compensation coverage (statutory and policy) of employers and injured employees.   

• Determines, documents, and manages the on-going medical treatment program including directing care, creating jurisdictional specific panels, and approving provider requests.  

• Remains abreast of new case law decisions affecting claim and medical management. 

• Monitors the work status of the injured workers.