Position Description
Reviews, analyzes and evaluates medical information pertaining to first or third party injury claims. Coordinates and manages the medical cost management programs.
Position Requirements
Acts as a triage agent between the adjuster and the Independent Medical Examination (IME), peer review and medical cost containment options. Recommends cost containment advice to adjusters on excessive treatment, CAT claims, lost wage cases, and Surgical Procedures and Diagnostic testing. Provides further cost containment recommendations based upon Sentry rules and system edits. Runs analytical reports in Crystal Reports to capture treatment patterns of concern and addresses behaviors with management staff for further handling.
Provides technical direction on first and third party medical claims. Provides case management recommendations within claim files relative to billing patterns.
Makes determinations regarding casual relationships, appropriate treatments, implications regarding potential medical outcomes and costs, legitimacy of alleged injuries and development or existence or pre-existing and unrelated injuries.
Conducts in-house medical training, conferences with claim staff, participates in roundtable discussions and maintains current medical resource library. Provides back-up and guidance to medical coders as requested.
Performs other related duties as required.
Education Requirements
- Associates degree in Nursing, RN or LPN license
- Five (5) or more years of progressively more responsible experience in clinical medical treatment (orthopedics preferred); claims administration, evaluation and settlement
- Knowledge of medical terminology, diagnoses and treatments 4+ years NJ PIP experience
- Superior negotiation, communication and organizational skills
- Knowledge of insurance claims including settlement and administration
- RN or LPN license and 3 years claims administration, evaluation and settlement
- Technical knowledge of the medical field and industry
- Working knowledge of clinical medical terminology, diagnosis, medical procedures, treatments and prognosis.
- Working knowledge of medical claims administration procedures and related legal and regulatory requirements and guidelines.
- Communication Skills (written and verbal)
- Computer literacy: spreadsheet, database, word processing, etc. skills
