Auto First Party Medical Claim Representative
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Job Description SummaryThis position is responsible for handling Personal and Business Insurance First Party Medical claims from the first notice of loss through resolution/settlement and payment process. This may include applying laws and statutes for multiple state jurisdictions. Provides quality claim handling throughout the claim life cycle (customer contacts, coverage, investigation, evaluation, reserving, negotiation and resolution) including maintaining full compliance with internal and external quality standards and state specific regulations. 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.
Primary Job Duties & Responsibilities
- Customer Contacts/Experience:
- Delivers consistent service quality throughout the claim life cycle, including but not limited to prompt contact, explaining the process, setting expectations, on-going communication, follow-through and meeting commitments to achieve optimal outcome on every file. Fulfills specific service commitments made to certain accounts, as outlined in Special Account Communication (SAC).
- Coverage Analysis:
- Reviews and analyzes coverage and applies policy conditions, provisions, exclusions and endorsements for assigned jurisdictions. Verifies the benefits available, the injured party's eligibility and the applicable limits. Addresses proper application of any deductibles, co-insurance, coverage limits, etc. Confirms priority of coverage (i.e. primary, secondary, concurrent) and takes into consideration other issues such as Social Security, Workers Compensation or others relevant to the jurisdiction.
- Investigates each claim to obtain relevant facts necessary to determine coverage, causation/damages, medical necessity, treatment plan, damages, and exposure with respect to the various coverages provided through prompt contact with appropriate parties (e.g. policyholders, medical providers and technical experts). This may also include investigation of wage loss and essential services claims. Takes recorded statements as necessary.
- Proactively manages medical treatment based on the nature and extent of injury, mechanism of injury, type of treatment received or anticipated, and wage loss through case management and use of medical resources as needed. Proactively manages the process to ensure proper payment, (i.e. review medical bills and medical records for appropriateness of billing/fees and the services rendered ensuring that all records have a determination of medical necessity and causal relationship to the loss).
- Establishes timely and maintains appropriate claim and expense reserves to reflect the overall claim exposure. Manages file inventory and expense reserves by utilizing an effective diary system, documenting claim file activities to resolve claim in a timely manner.
- Determines settlement amounts, negotiates and conveys claim settlements within authority limits to insureds and claimants. As appropriate, writes denial letters, Reservation of Rights and other necessary correspondence to insureds and claimants.
- May handle litigated files on appropriately assigned cases. Develops resolution plan with staff or panel counsel, and track and control legal expenses; Reviews conciliations and prepares submissions for arbitration and/or mediation hearings. May also attend arbitrations as Company witness.
- Insurance License:
- 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.
- High School Degree or GED with a minimum of one year auto claim handling experience or successful completion of Travelers Claim Representative training program required.
Education, Work Experience, & Knowledge
- Associate's Degree or Bachelor's degree with 2 years auto claim handling experience preferred.
- Prior Auto First Party Medical experience preferred.
- Knowledge of medical terminology preferred.
Job Specific Technical Skills & Competencies
- Demonstrated ownership attitude and customer centric response to all assigned tasks.
- Attention to detail ensuring accuracy.
- Ability to work in a high volume, fast paced environment managing multiple priorities.
- Keyboard skills and Windows proficiency, including Excel and Word - Intermediate
- Verbal and written communication skills - Intermediate
- Analytical Thinking: Intermediate.
- Judgment/Decision Making: Intermediate.
- Negotiation: Intermediate.
- Insurance Contract Knowledge: Intermediate.
- Principles of Investigation: Intermediate.
- Value Determination: Intermediate.
- Settlement Techniques: Intermediate.
- Legal Knowledge: Basic.
- Medical Knowledge: Intermediate.
Environmental / Work Schedules / Other
- Travel Requirements: Travel Occasionally
Travelers is an equal opportunity employer. We value the unique abilities and talents each individual brings to our organization and recognize that we benefit in numerous ways from our differences.
If you are a candidate and have specific questions regarding the physical requirements of this role, please send us an email so we may assist you.
Travelers reserves the right to fill this position at a level above or below the level included in this posting.