Claims Adjuster

Qualifications

• 1 year of 1st party injury medical claims adjusting and Adjuster Desktop application or auto liability adjusting experience to include highly complex vehicle physical damage, such as multi-vehicle, non-owned vehicles, or total loss claims.
• Working knowledge and understanding of the auto claims contract, investigation, evaluation, negotiation, and accurate adjudication of claims as well as application of case law and state laws and regulations.
• Ability to evaluate, prioritize and make informed decisions to ensure timely and accurate completion.
• Ability to interpret data, facts, and situational information and make concise decisions to resolve issues in a quick fashion.
• Demonstrated negotiation, investigation, communication, and conflict resolution skills.
• Proven investigatory, prioritizing, multi-tasking, and problem-solving skills.
• Medflow and Guide Wire

Responsibilities:

• Primary liaison/contact person for medical bill audit (MBA) services for issues or communications between the vendor, Injury Adjusters, and/or Claims Staff. Works closely with front-line employees and managers, and provides additional training as needed. Reviews reports to detect any opportunities and reports these to their management team
• Identifies and manages existing and emerging risks that stem from business activities and the job role.
• Ensures risks associated with business activities are effectively identified, measured, monitored, and controlled. Follows written risk and compliance policies, standards, and procedures for business activities.
• Identifies training needs, facilitates and coordinates provision of formal MBA related training, and assists with providing formal and informal training, as needed, to include coordinating with the Injury Adjusters and management as appropriate.
• Based on feedback and review of the process, identifies efficiencies to improve the experience for the member and the employee while remaining compliant with state regulations.
• Reviews medical bill audit activity reports, identifies necessary actions or issues relative to the report, and facilitates completion of identified actions based on the service level objective (SLO).
• Assists management and/or member relations with responding to complaint letters regarding payments by Adjusters based on medical bill audit recommendations from Departments of Insurance, Attorneys, members/insured's, and/or providers.
• Maintains day-to-day currency of user web access list and communicates daily to MA Supplier with access changes for users.