Medical Claims Representative

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EMC Insurance Companies

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1911

Insurance

EMC Insurance Companies is a mutual insurance firm providing specialized business insurance solutions. They focus on commercial property insurance, liability insurance, workers' compensation, and business owners' policies. With a strong emphasis on personalized service, EMC collaborates closely with local agents to deliver comprehensive and tailored coverage. EMC is committed to understanding the unique challenges faced by its policyholders, offering risk management and loss control resources to help businesses safeguard their assets. Known for their dedicated partnerships and exceptional customer service, EMC ensures that businesses are prepared for the unexpected with their superior insurance solutions.

📋 Description

• Investigates and evaluates medical only (MO) claims within multiple jurisdictions • Reviews the claim notice and policy to verify coverage, deductibles, compensability, and jurisdiction compliance • Initiates prompt contact with customers to obtain information and explains the claim process • Makes timely contact with insureds, injured employee(s), and witnesses when necessary and documents calls, and activities undertaken within the claims system • Confirms return to work status with insureds • Confirms appropriate medical care, including use of appropriate cost containment techniques and resources, and takes appropriate actions • Sets timely, adequate reserves in compliance with the company reserving philosophy and methodology • Provides prompt, detailed responses to agents, insureds, and injured employee on the status of claims • Escalates claims to their people leader as appropriate • Maintains accurate and timely diaries on all files to handle claims and bring a resolution • Completes state reporting as required within jurisdictional guidelines • Secures all the necessary reports, claims forms and documents • Documents claim handling activity via claim notes, including Medicare (MSP) modules in the claims system • Drafts and sends denial letters upon manager approval • Issues timely payments within check authority limit • Submits referrals to Medical Management and Medical Review Units as appropriate • Markets OnCall Nurse (OCN), Return to Work (RTW), Select Preferred Provider (SPP) to insured’s and identifies non-use for corrective measures • Prepares risk reports for Underwriting • Assists Claims team members with the handling of claims as needed • Attends internal and external training and self-study to keep abreast of changes relating to medical treatment, and jurisdictional and statue changes impacting workers compensation benefits • Completes ongoing continuing education to remain compliant with jurisdictional licensing requirements.

🎯 Requirements

• Associate degree or equivalent relevant experience • One year of insurance or claims handling experience or related experience • Bachelor’s degree may be considered in lieu of the experience requirement • Attainment of all applicable state licenses within six months of hire • Basic knowledge of claims adjusting process preferred • Good knowledge of computers • Good investigative and problem-solving abilities • Ability to multi-task and prioritize deadlines • Strong organizational, written and verbal communication skills • Strong customer service skills • Ability to adhere to high standards of professional conduct and code of ethics • Ability to maintain confidentiality

🏖️ Benefits

• Outstanding benefits with life, medical, dental, vision and prescription drug coverage • Competitive paid time off plan and a full day of volunteer time off annually • Financial incentives, including a 401(k) plan match, pension plan, OneEMC bonus plan and recognition and anniversary awards • Professional development and growth opportunities, including tuition reimbursement • Wellness initiatives to improve team member well-being and reduce health insurance costs • Flexibility to dress for your day and opportunities for alternative work arrangements