About Us
At Missouri Employers Mutual, we're driven by a passion for keeping people safe. Our mission is to make a positive impact on the way people live and work, and we're committed to creating a values-driven work culture that fosters growth and success. If you share our vision and values, we invite you to join our team as an Experienced Medical Only Claims Representative.
Job Summary
We're seeking an experienced Medical Only Claims Representative to join our team in a remote capacity. As a key member of our claims handling team, you'll be responsible for investigating, evaluating, and bringing to disposition assigned Medical Only claims, following sound claims handling techniques and in accordance with company claims philosophy, statutory requirements, and quality assurance standards.
Key Responsibilities
- Investigates assigned claims for coverage, promptly notifying Corporate Claims of any issues, so that MEM's position can be evaluated and appropriate correspondence issued. Documents every claim with a coverage analysis notepad.
- Manages assigned medical-only claims, identifying when a case is more complex or potentially fraudulent and needs escalation. Ensures all claims comply with state regulations, referring those involving compensability, potential fraud, or other violations to the appropriate team for further investigation.
- Oversees the medical aspects of the files to ensure quality care in a cost-effective manner. This includes working with network providers, referring to Utilization Management, and engaging Nurse Case Management when appropriate. Reviews and processes medical bills in a timely manner.
- Identifies subrogation, investigates and documents third-party liability to maximize potential recovery dollars.
- Establishes and maintains claim reserves, which in the aggregate are sufficient to discharge ultimate corporate liability. This requires timely responsiveness to changing claim circumstances, with avoidance of stair-stepping or significant adverse development. File documentation should be sufficient to explain the rationale for reserve changes. Secure approval for any reserves beyond stated authority.
- Recognizes claims with Medicare exposure and works with Corporate Claims to ensure we protect Medicare's interests and required reporting.
- Documents files with all relevant facts and actions taken, action plan, necessary reports, investigative notes, and other data as may be required by the state Workers' Compensation Law, Federal Longshore and Harbor Workers' Compensation Act, the State Insurance Department, and MEM guidelines.
- Ensures system data integrity by entering and maintaining accurate information in required fields.
- Maintains cross-departmental teamwork and communication with other operational units across MEM (e.g., Underwriting, Premium Consultation, Safety & Risk Services, etc.).
- Provides appropriate level of service to both internal and external customers, communicating claim status to Producers and Policyholders as requested. Complies with standards for service and initial contacts. Takes prompt action to respond to and resolve complaints and problems. Assists Policyholders and producers with questions or training needs as requested.
- Manages assigned caseload effectively and in accordance with productivity standards, prioritizing workflow tasks to move cases to closure. Promptly identifies emerging issues on assigned files to reassign quickly to field claim staff when appropriate.
- Successfully performs other duties in relation to training and development required for advancement to an Associate Claims Representative.
- Ability to effectively communicate and work with individuals who may present challenging situations or behavior, which can sometimes include cultural and/or language barriers.
- Performs other duties as may be dictated by office/department/corporate circumstances.
Qualifications
To be successful in this role, you'll need:
Education
- High School Diploma or Equivalent is required.
- Bachelor's degree is preferred.
Designations/Certifications
- AIC or other insurance designation is preferred. None required.
Licenses
- A valid driver's license is required.
Experience
- 1+ years of directly related work experience in a medical or insurance setting. Must have experience processing insurance claims, workers' compensation experience preferred.
What We Offer
As a Medical Only Claims Representative at Missouri Employers Mutual, you'll enjoy:
Competitive Compensation
We offer a competitive salary that reflects your skills and experience.
Remote Work Opportunities
Work from the comfort of your own home and enjoy a better work-life balance.
Opportunities for Growth and Development
We're committed to helping you grow and develop in your career, with opportunities for training and advancement.
Collaborative and Supportive Work Environment
Join a team that values collaboration, communication, and mutual respect.
Benefits and Perks
We offer a range of benefits and perks, including health insurance, retirement plans, and paid time off.
How to Apply
If you're a motivated and experienced Medical Only Claims Representative looking for a new challenge, we invite you to apply for this exciting opportunity. Click the link below to submit your application:
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Simple Application Process
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