Claims Resolution Specialist II, No Fault

Manages, investigates and resolves medical claims assigned by the Claims Team Manager and assists in providing service to policyholders and agents under general supervision. May perform field investigation on assigned cases and make recommendations on additional work as indicated. Recognizes and solves problems of moderate scope and complexity.

Training is a critical component to your success and that success starts with reliable attendance.  Attendance and active engagement during training is mandatory

NJ No Fault experience is required.

Responsibilities:

• Manages, evaluates and resolves claims assigned by Claims Team Manager. Evaluates liability, medical necessity, causality and settles claims within prescribed authority.
• Communicates with policyholders, agents, witnesses, and claimants in order to gather information regarding claims and refers tasks to auxiliary resources as necessary. Responds to various written and telephone inquiries including status reports.
• Reviews medical records and bills to verify claimed treatment is causally related to the accident and is reasonable and necessary given facts of the claim.
• Ensures adequacy of reserves and settlement authority.
• Confirms or denies coverage and liability and advises policyholders, agents and claimants as to proper course of action.
• Makes effective use of loss management techniques (IMEs, Nurse Review, and Bill Review). Negotiates settlements with attorneys, claimants, and medical providers. Arranges for expert inspections involving third party or potential fraud actions as needed.
• Updates files and provides comprehensive reports as required.
• Identifies and recommends referral of potentially fraudulent claims to the Special Investigation Unit.
• Recognizes continuous improvement opportunities and develops.

• Strong written and oral communications skills required. Good interpersonal, analytical, decision making, and negotiation skills required.
• Customer service experience preferred.
• Knowledge of legal liability, general insurance policy coverage and the ability to review and understand medical records to determine causality and medical necessity.
• The capabilities, skills and knowledge required is normally acquired through a Bachelor’s degree or equivalent experience and 6-12 months of directly related experience.
• Ability to obtain proper licensing as required.