Medical Only Claims Examiner
- Career Level
- Entry Level
The Medical Only Claims Examiner is the first professional level of claim administration. This level examiner is closely supervised, has a general understanding of department objectives and is sufficiently knowledgeable in workers’ compensation laws to administer medical claims benefits. This position, is responsible for determining the validity of workers' compensation claims only involving medical workers' compensation benefits. The medical-only claims adjuster will also establish medical treatment reserves, approve and process medical benefits, and negotiate settlement of medical benefit claims. Medical Only claims consist of non-litigated, no lost time, soft tissue type injuries, including strains/sprains. In addition this position will also back-up the First Report Unit and Claims Assistant ACD phone group. Claims handling activities will be performed in compliance with the rules, regulations and statutes of the WCAB and the State of California. This position requires the Medical Only Claims Examiner to be certified pursuant to California statute. This may be done by classroom instruction, on the job experience, or some combination of both, in order to obtain the required 80 hours under supervision during the first year in the job.
- Provide customer service – answer telephones by the third ring and re-direct callers as necessary to properly respond to customer inquiries
- Complete three-point contact to properly investigate assigned claims, evaluate coverage and determine compensability.
- Perform data entry to setup new claims, work diaries and create activity notes.
- Calculates and assigns timely and appropriate reserves to claims. Reserves should take into account likely medical and expense exposure. If indemnity or complicated medical issues arise, notifies supervisor/manager of the need to re-assign the claim file to a Claims Examiner.
- Complete and prepare documentation for referrals to investigators and copy service subpoenas.
- Manage initial and subsequent treatment within the Medical Provider Network.
- Assist in the delivery of medical care in accordance with the MTUS and Utilization Review.
- Appropriately initiate QME process for unrepresented claims.
- Complete assigned work via diaries and work queues in a timely manner.
- Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims.
- Perform other duties as requested by supervisor/manager