Senior Medical Specialist, PIP, Med Pay

The salary range for this job posting is $55,132.00 - $88,210.00 annually + bonus + benefits

The above represents the 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. Your recruiter can share more information about the specific salary range during the hiring process.

Encova Insurance has an immediate opening for a Senior Medical Specialist with experience handling Michigan personal injury protection claims and Michigan Catastrophic Claims Commission reporting. This is a home-based position but you must reside in one of our eligible payroll states as listed on our careers page.

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:

Investigate, evaluate and process medical claims within established best practices and applicable jurisdictional guidelines. 

ESSENTIAL FUNCTIONS: 

• Handle medical claims including medical payments both first and third party, PIP, no-fault and first party benefits, and any supplementary coverage such as wage loss, essential services and funeral benefits.  
• Review and analyze coverage (including complex coverage issues), apply policy conditions, provisions, exclusions and endorsements, and confirm priority of coverage.  Verify the benefits available and the applicable limits and address proper application of any deductibles and co-insurance. When necessary, retain and work with coverage counsel.
• Investigate and gather information, including taking statements as necessary, to determine the facts of loss and subrogation potential. 
• Proactively manage and continuously evaluate medical treatment based on the nature and extent of injury.  Recognize causality, medical necessity and over-utilization issues. Conduct a medical history investigation as necessary.
• Determine and continually evaluate appropriate reserves.  
• Establish a plan of action and utilize appropriate resources as necessary to move the file towards resolution.  Investigate and close an average of at least 60 losses per month.
• Communicate with all stakeholders clearly, accurately and professionally.
• Comply with Encova’s claims organization policies, established best practices and jurisdictional guidelines.
• Complete necessary reports and authorization requests.
• Maintain competency in the use of multiple claims systems and manage efficient and effective follow-up practices.  
• Obtain state licensing as required.  
• Serve as a member of claims and other company integrated teams as assigned.
• Recognize when additional claim exposures need to be opened and take appropriate steps to do so.
• Serve as a subject matter expert within Claims as well as other areas of the company.

OTHER FUNCTIONS: 

• Maintain an ongoing understanding of claims processes and procedures, and keep current on fair claims practices laws, compliance issues, and business-related developments.
• Maintain open lines of communications with all stakeholders including claims resolution specialists that may be involved in the handling of other elements of the file. 
• Attend seminars and workshops as required.
• Perform other duties as assigned.
• Make limited outside contacts at the direction of the team lead.

KNOWLEDGE. SKILLS AND EXPERIENCE:

• This position requires a minimum of 10 years’ experience as a claims resolution specialist or equivalent experience in the insurance industry or health care field. 
• Desirable candidates will possess at least five years’ experience handling Michi