Medical Only Claim Specialist
About the Job
**14626BR** **Title:** Medical Only Claim Specialist **Target Openings:** 1 **Primary Job Duties & Responsibilities:** Identify red flags or other issues, such as medical treatment in excess of 180 days or $5,000 in medical expenses, or 90 days if the injured worker is on modified duty. Evaluate the need to transfer from medical only to the Investigative Case Unit or Return to Work Unit as appropriate. Respond to insured and injured worker and provider inquiries as necessary. Determine causal relatedness and medical necessity of minor medical conditions/treatment through the use of tools/guidelines (medical guidelines, medical position statements, etc.). Coordinate medical treatment as appropriate: Review, approve and make accurate/timely payment of appropriate medical bills and expenses in compliance with State regulations. Channel to preferred network as appropriate. Complete denials limited to medical issues and communicate denials to impacted parties. Identify the need for and engage nurse resource for utilization review when appropriate. File appropriate state forms. In order to perform the essential functions of this job, acquisition and maintenance of Insurance License(s) may be required to comply with state and Travelers requirements. Generally, license(s) must be obtained within three months of starting the job and obtain ongoing continuing education credits as mandated. Maintain Continuing Education requirements as required. Perform other duties as assigned. **Job Opening ID:** 14626BR **Equal Employment Opportunity Statement:** Travelers is an equal opportunity employer. **Job Specific & Technical Skills & Competencies:** Analytical Thinking: Identifies current or future problems or opportunities; analyzes, synthesizes and compares information to understand issues; identifies cause/effect relationships; and explores alternative solutions that support sound decision-making. Strong attention to detail. Judgment/Decision Making: Exercises sound judgment. Makes decisions and commits to a position. Communication: Able to communicate information in terms that can be easily understood by others. Expresses, summarizes and records thoughts clearly and concisely orally and in writing by applying proper content, format, sentence structure, grammar, language and terminology. Negotiation: Ability to understand alternatives, influence stakeholders and reach a fair agreement through discussion and compromise. Principles of Investigation: Follows a logical sequence of inquiry with a goal of arriving at an accurate reconstruction of events related to the loss. Legal Knowledge: General knowledge, understanding and application of state, federal and regulatory laws and statutes related to Workers' Compensation. Medical knowledge: General knowledge of the nature and extent of injuries, periods of disability, and treatment needed. Customer Service: Demonstrated ability to build and maintain productive relationships with our insureds and deliver results with optimal outcomes Teamwork: Advanced ability to work together in situations when actions are interdependent and a team is mutually responsible to produce a result Planning & Organizing: Advanced ability to establish a plan/course of action and contingencies for self or others to meet current or future goals **Job Category:** Claim **Job Summary:** Under moderate to direct supervision, this position is responsible for: Reviewing/evaluating, approving and processing Medical Only claims with: No lost time beyond statutory waiting period No salary continuation A return to full time work within 90 days if the injured worker is on modified duty and/or total medical paid generally not to exceed $5,000. No attorney involvement or ongoing litigation As part of the hiring process, this position requires the completion of an online pre-employment assessment. Further information regarding the assessment including an accommodation process, if needed, will be provided at such time as your candidacy is deemed appropriate for further consideration. **Position Type:** Experienced/Professional **Education, Work Experience & Knowledge:** College degree highly preferred. 1-2 year related business experience preferred. Bilingual candidates are encouraged to apply. **Physical Requirements:** Operates standard office equipment (Frequency) Sitting (Can stand at will) (Frequency) Use of Keyboards, Sporadic 10-Key (Frequency) **Minimum Qualifications:** High School Diploma or GED and one year of customer service experience OR Bachelor's Degree required. **Company Information:** Solid reputation, passionate people and endless opportunities. That's Travelers. Our superior financial strength and consistent record of strong operating returns mean security for our customers - and opportunities for our employees. You will find Travelers to be full of energy and a workplace in which you truly can make a difference. **Primary Location:** Albuquerque - New Mexico - United States We are committed to valuing the diversity that exists among our workforce, our business partners, our customers and our communities. With respect to our workforce, we are committed to not only increasing diversity in our hiring at all levels but also fostering an inclusive environment where all employees, regardless of race, color, religion, gender, gender identity, age, national origin, disability, veteran status, marital status, sexual orientation, genetic information or any other status or condition protected by law, can develop and thrive.