Medical Management Specialist

Position Summary

Do you have a passion for helping people through the claims process, especially when medical recovery and compassion matter most? Erie Insurance is seeking a Medical Management Specialist to join our New York Branch team in Rochester. This position plays a vital role in handling first‑party medical benefit claims and ensuring our policyholders receive the care and support they deserve.

There is a potential for multiple positions to be available.

• Manage first-party medical benefit claims, including wage loss and fatality claims.
• Investigate coverage, determine claim value, and ensure compliance with applicable state laws.
• Analyze medical records and wage documentation to reach fair, accurate claim conclusions.
• Collaborate with legal counsel on litigation cases and coordinate with investigative services when necessary.
• Maintain contact with policyholders, claimants, agents, and medical providers to deliver outstanding service.
• Assist in training branch staff and stay current on laws and medical management best practices.

You’re detail-oriented, empathetic, and confident managing complex medical claim situations. You combine strong analytical skills with a calm, professional approach to resolving claims efficiently and fairly.

Within designated authority, handles medical management claims with limited supervision.

• Handles first party medical benefit claims, including fatalities and wage loss claims. Evaluates and makes decisions regarding coverage. Conducts investigations, determines total value of claims, sets and maintains adequate reserves, and manages cases.
• Prepares related correspondence and reports, obtains medical and employment related records, calculates wage loss claims per applicable state laws and brings claims to conclusion.
• Investigates, evaluates, and resolves coverage questions in compliance with applicable state laws.
• Establishes immediate contact with Policyholders and Claimants. Contacts Agents as necessary.
• Reviews claim files on a regular basis and takes necessary follow-up and/or closing action.
• Evaluates, processes and takes appropriate action on claim-related bills and medical, rehabilitation and special investigative reports. Determines claims to be paid, compromised or contested.
• Coordinates activities with the Home Office on serious or massive injury cases. Notifies company investigative services of cases involving suspected fraud.
• When appropriate manages claims in litigation and assist in the development of case strategy with legal counsel.

• Attends industry-related training programs to stay current on legal developments and ensure compliance with applicable laws and regulations impacting the operation of the department.
• Assists or acts on the behalf of supervisor when required, including handling of insurance department complaints.
• When appropriate identifies subrogation situations and initiates appropriate action.
• Develops expertise in legal and medical terminology and procedures.
• Assists in training branch office personnel in related matters.
• Assigns, monitors and controls activities of vendors in a cost-effective manner.

• Values Diversity
• Job‑Specific Knowledge
• Self‑Development
• Nimble Learning
• Collaborates
• Customer Focus
• Cultivates Innovation
• Optimizes Work Processes (IC)
• Instills Trust Ensures Accountability
• Decision Quality

• High School Diploma or GED and two years of general claims handling experience required, or;
• Bachelor’s Degree required.
• OR completion of formal ERIE training program, required.

• Strong working knowledge of applicable state laws preferred.
• Good working knowledge of human anatomy and medical terminology preferred.
• Expertise in state no-fault laws and working knowledge of civil law preferred.
• Working knowledge of medical bill repricing system preferred.

• Successful completion of AIC courses preferred.
• Appropriate license as required by state.

• Lifting/Moving 0-20 lbs;
  Occasional
• Lifting/Moving 20-50 lbs;
  Occasional
• Ability to move over 50 lbs…