Medical Only Claims Adjuster

Medical Only Claims Adjuster

Requirements

• Bachelor’s degree from an accredited university or industry designations are preferred but not required. Two or more insurance designations or six additional years of related industry experience beyond the minimum experience required above may be substituted in lieu of a degree.
• A working knowledge of medical only claims typically achieved through: Less than two years’ experience adjudicating medical only claims.
• At least one year of experience in the insurance or healthcare industry (preferably in a commercial claim department) is required, as is familiarity with medical terminology.
• Must have good business acumen (i.e. understand how an insurance company works and makes money, including how this role impacts both Argo Group and our customers’ ability to be profitable).
• Must work independently and demonstrate the ability to exercise sound judgment with respect to matters of significance. This role faces issues that are moderately complex and not immediately evident.
• Must have excellent communication skills and the ability to build lasting relationships.
• Exhibit natural and intellectual curiosity in order to consistently explore and consider all options and is not governed by conventional thinking.
• Desire to work in a fast-paced environment.
• Excellent evaluation and strategic skills required.
• Strong claim negotiation skills a must.
• Must possess a strong customer focus.
• Effective time management skills and ability to prioritize workload while handling multiple tasks and deadlines.
• Must be tenacious in ability to investigate claims by interviewing injured worker, employer, witnesses, and healthcare providers and researching coverage issues and potential subrogation opportunities.
• The ability to read, speak, and write English fluently is required. Polished and professional telephone communication skills are essential. The ability to read and write Spanish fluently is not required but is preferred.
• Must demonstrate the ability to exercise sound judgment working under moderate supervision.
• Demonstrates inner strength. Has the courage to do the right thing and demonstrates it on a daily basis.
• Proficient in MS Office Suite and other business-related software.
• Polished and professional written and verbal communication skills are essential.
• Must demonstrate a desire for continued professional development through continuing education and self-development opportunities.
• Licensed Claims Examiner (Based on state) Must be licensed or have ability to quickly obtain a license in each jurisdiction requiring a license to adjudicate first party claims within 120 Days.

Responsibilities

• Under close supervision and guidance, works within narrowly defined limits with an impact on departmental results – this requires calling the claimant, insured employer, healthcare provider, and witnesses to determine compensability issues and subrogation potential.
• Resolving issues that are generalized and typically not immediately evident, but typically not complex and within immediate job area.
• Denying any claims that are not covered or do not meet compensability criteria and successfully defending that decision if challenged.
• Actively manage medical only claims to ensure only medical bills appropriate to the claim are paid on a timely basis.
• Managing a diary and completing tasks to ensure that cases are resolved timely and at the right financial outcome.
• Properly setting claim reserves.
• Identifying and directing the assignment and coordination of expertise resources to assist in case resolution.
• Preparing reports for file documentation.
• Processing mail and prioritizing workload.
• Responsible for telephone calls from various parties (insured, claimant, etc.).
• Having an appreciation and passion for strong claim management.

Preferred Qualifications

• Two or more insurance designations or six additional years of related industry experience beyond the minimum experience required above may be substituted in lieu of a degree.
• The ability to read and write Spanish fluently is not required but is preferred.