Claims Specialist-WC

Administers and resolves non-complex short term claims of low monetary amounts, including medical only claims. Documents and monitors open case inventory and ensures proper and timely closing of files. Makes decisions on claims within delegated limited authority.

• Conducts investigations of claims to confirm coverage and to determine liability, compensability, and damages. Works closely with claimants, witnesses and members of the medical profession and other persons pertinent to the investigation and processing of claims.


• Verifies policy coverage for submitted claims and notifies the insured of any issues; determines and establishes reserve requirements, adjusting reserves, as necessary, during the processing of the claim.


• Identifies wage loss expenses and wage exposures on medical claims.


• Documents receipt and contents of medical reports. Interacts frequently with claimant to understand nature and extent of injury and medical conditions. Reviews and handles other correspondence within authority including material from the team members, and/or clients.


• Approves payments of medical bills on lost time disability claims within area of payment authority up to, but not exceeding, $2,500 after compensability has been determined.


• Evaluates medical claims for potential fraud issues, loss control and recovery in accordance with insurance policy contracts, medical bill coding rules and state regulations.


• Keeps Team Manager informed verbally and in writing of activities and problems within assigned area of responsibility; refers matters beyond limits of authority and expertise to Team Manager for direction.


• With the team managers guidance, provides input on the completion of status reports, initiate's activity checks and/or widow's statement of dependency forms.


• Completes all reporting forms and file documentation.


• Adheres to client and carrier guidelines and prepares written updates for supervisor to review.


• Performs other related duties as required or requested.

• College degree or the equivalent of education and experience.


• Knowledge of claims and familiarity with claims terminology gained through industry experience and/or through specialized courses of study (Associate in Claim designation, etc).


• Demonstrates a thorough working knowledge of claim processing and claim policies and procedures.


• Demonstrates an understanding of basic medical terminology and appropriate medical tests for claimed conditions


• Demonstrates effective and diplomatic oral and written communication skills.


• Demonstrates a customer-focused approach including the ability to identify and understand customer needs, and interacts effectively with others.


• Must have or secure and maintain the appropriate license(s) as required by the state(s) at the adjuster/supervisory/management level. Must possess a valid driver's license. Must complete continuing education requirements as outlined by Crawford Educational Services. Additional courses may be required by jurisdiction for maintenance of license.

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