Claims Specialist I, Medical
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JOB SUMMARY: Evaluates Personal Injury Protection (PIP), Med Pay and Med Ben claims for eligibility, medical necessity, appropriateness of charges and in accordance with state fee schedules. Determines relatedness, casualty, and appropriateness of treatment based on the compensable injury. Makes payment decisions based on policy provisions, state mandates, departmental policies, medical and non-medical information. Promotes and provides "On Your Side" customer service. Evaluates and investigates first party medical claims. Makes payment decisions based on policy provisions, state mandates, departmental policies, medical and non-medical information in accordance with Best Claims Practices.
Accurately pays claims based on policy provisions, state mandates and/or fee schedules.
Initiates and conducts follow-ups via proficient use of claims systems and related business systems
Determines and initiates appropriate requests for medical and non-medical information needed to properly pay claims.
Determines applicable coverage, medical necessity and appropriateness of charges related to injury claim.
Partners with SIU and Subrogation to identify fraud and subrogation opportunities.
Maintains and develops current knowledge of: assigned insurance lines; court decisions which may impact the claims function; current guidelines in the claims function; and policy changes and modifications. This may require attendance at various seminars or training sessions.
Reviews and researches medical bills and surgical reports obtained from providers for contestability and pre-existing health history.
Submits severe incident reports, reinsurance reports and other information to claims management as needed.
Delivers a positive On-Your-Side customer service experience to all internal, external, current and prospective Nationwide customers.
Communicates regularly with policyholders, agents, providers and field claims representatives through telephone calls, and letters.
Initiates and conducts follow-ups via proficient use of claims systems and related business systems.
Other duties as assigned.
Education: Undergraduate degree or equivalent experience preferred.
Licenses/Designations: State licensing where required. Successful completion of required claims certification schools/classes.
Experience: One to three years of customer service and/or claims processing/handling experience preferred.
Knowledge: General knowledge of insurance theory and practices, insurance contracts and their application. Familiarity with claims processing and medical terminology. Familiarity with related claims best practices and procedures preferred.
Skills/Competencies: Proven ability to meet customer needs and provide exemplary service by informing customers of the claims process and ensuring a positive customer experience. Proven analytical skills necessary to make decisions and resolve conflict in such areas as application of coverages to submitted claims, application of laws of jurisdiction to investigatory facts application of policy exclusions and exceptions. Organizational skills to effectively prioritize work. Proven written and verbal communication skills for contact and/or negotiation with policyholders, claimants, peers, attorneys, physicians, agents and the general public. Ability to efficiently operate personal computer and software for claims-related and other business applications.
Values: Regularly and consistently demonstrates the Nationwide Values and Guiding Behaviors.
Staffing Exceptions to the above Minimum Job Requirements must be approved by: Business Unit Executive and Human Resources.
Working Conditions: Office claims environment. Require ability to sit and operate telephone and personal computer for extended periods of time. Must be willing to work extended hours and to travel with possible overnight requirements. Must be available to work catastrophes (CAT) requiring travel to CAT sites with multiple on-site responsibilities and/or for extended periods of time. Including holidays and week-ends.
Credit/Background Check: Due to the fiduciary accountabilities within this job, a valid credit check and/or background check will be required as part of the selection process.
ADA: The above statements cover what are generally believed to be principal and essential functions of this job. Specific circumstances may allow or require some people assigned to the job to perform a somewhat different combination of duties.
Job Evaluation Activity: Edited 5/2/11 JTG
Additional Job Description
Job ID: 53884
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