Medical Only Claims Specialist - Workers' Compensation

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.

We will consider those who reside in any of our listed payroll approved states with the related experience.

Ideal candidates will have Workers' Compensation claims handling experience. Multiple jurisdictions will be included in this role and Virginia, North Carolina and South Carolina experience 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 quality medical care.
15. Along with the claim director, regional vice president and other claims staff, participates in claim reviews, onboardings, etc. for our policyholders and agents.
16. Proactively collaborate with our policyholders to ensure alignment of objectives and foster continuous improvement.

OTHER FUNCTIONS:
1. Nonessential function: other duties as assigned.

KNOWLEDGE, SKILLS AND ABILITIES:
• Bachelor’s Degree from an accredited college or university is preferred.
• One year of experience in the field of insurance, customer service, claims investigation, legal, rehabilitation, or medical claims processing required. Workers’ compensation claims experience and licensure preferred.
• Must pass the claims adjuster license exam(s) as assigned within 6 months of being hired.
• Preference may be shown to candidates with multiple state claims management experience.
• Ability to use logic and sound reasoning to identify alternative solutions for problem-solving.
• Strong written and verbal communication skills.

• Strong analytical skills.

• Ability to multitask and manage time effectively and productively.
• Work effectively independently as well as in a team environment.
• Develop and maintain strong, effective internal and external relationships.
• Work effectively in a paperless environment.
• Skilled in the use of laptops, claims management systems, and other typical business-related programs such as Microsoft Office suite.

This position has been evaluated in accordance with the Americans with Disabilities Act. Encova Insurance makes every effort to reasonably accommodate disabilities to permit performance of the essential functions and candidates who need such accommodation are encouraged to seek it. This description reflects the nature and level of work performed by associates in this position. It is not an all-inclusive inventory of duties, responsibilities and qualifications required. It provides an accurate overview of the work and skills needed to perform this position. Because job content may change from time to time, Encova Insurance reserves the right to add and/or delete functions from this job as it deems necessary for business reasons.

Ready to join our team?
At Encova Insurance, we firmly believe that our associates drive our company's success by delivering unrivaled service to our customers. With success in mind, we make an ongoing effort to provide an environment that offers challenging, stimulating, and financially rewarding opportunities. Join us to discover a work experience where you can learn and grow to your fullest potential.

What you can expect from us

In addition to a competitive compensation package, we offer a comprehensive benefits package designed to support the well-being and growth of our associates. Available benefits (subject to any policy or plan changes) include, but are not limited to:

• Health, Dental & Vision Insurance

• Company-provided life and income protection plans

• Eligibility to participate in a company incentive bonus program

• 401(k) Retirement Plan - 100% company match up to 7% on annual salary

• Paid Time Off, Paid Holidays, and Floating Holidays

• Flexible Work Arrangements - Hybrid and remote depending on the role

We believe that happy, healthy associates are the foundation of great work. Join us and thrive both professionally and personally.

Encova Insurance is an EOE/E-Verify employer.