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Complex Claims Medical Analyst

Date: May 5, 2022

Location: Erie, PA, US, 16530

Company: Erie Insurance

Division or Field Office:

Claims Division

Department of Position: Corporate Claims Department 

Work from:

Home, within ERIE footprint

 

At Erie Insurance, you’re not just part of a Fortune 500 company; you’re also a valued member of a diverse and inclusive team that includes more than 5,000 employees and over 2,200 independent agencies.  Our Employees work in the Home Office complex located in Erie, PA, and in our Field Offices that span 12 states and the District of Columbia.  To attract and retain the best talent, we reward our team members with competitive salaries and a very generous benefits package.

 

Position Summary

  • This is a remote position that will allow the candidate to work from home anywhere within the ERIE footprint.

 

Exercises independent discretion in analyzing and direct handling of high exposure massive injury medical claims to determine benefits due, ensure ongoing adjudication of claims within service expectations and confirm adequate medical reserves. Ensures all aspects of an injured party's medical treatment is appropriate, cost effective, efficient and in accordance with applicable legal requirements.

Duties and Responsibilities

  • Handles complex/massive auto injury claims (i.e. life threatening injury resulting in a potential for long term mental and/or physical impairment, high medical costs, and/or total disability). Handles the medical portion of complex/massive Workers' Compensation injury claims.
  • Coordinates massive injury lifetime medical reserve reviews with Actuarial.
  • Identifies inappropriate, experimental, overutilization or costly medical treatment.
  • Complies with individual state legislation when applicable, regarding length of treatment guidelines and appeals time frames. Assures the timely and accurate determination and notification of medical treatment authorization, modification, delay or denial.
  • Assigns, monitors and controls activities of vendors in a cost-effective manner.
  • Provides medical education and guidance to claims staff as needed.
  • Assists in the ongoing improvement of the Managed Care Program.
  • Completes special projects as required.
  • Prepares cost projections, establishes and maintains medical reserves, manages cases and prepares related reports and correspondence. Investigates and researches statutes for unusual incidents. Maintains all records and related materials.
  • Assists defense counsel with litigated matters and makes recommendations regarding litigation (Auto Injury Claims).

Duties and Responsibilities (cont'd if applicable)

The first four duties listed are the functions identified as essential to the job. Essential functions are those job duties that must be performed in order for the job to be accomplished.

 

This position description in no way states or implies that these are the only duties to be performed by the incumbent. Employees are required to follow any other job-related instruction and to perform any other duties as requested by their supervisor, or as become evident.

Competencies

Values Diversity
Nimble Learning
Self-Development
Information Management Skills
Collaborates
Customer Focus
Job-Specific Knowledge
Cultivates Innovation
Instills Trust
Optimizes Work Processes
Decision Quality
Ensures Accountability

Qualifications

The minimum education and experience requirements are as follows:  Bachelor's degree, preferably in Nursing with five years experience in evaluating patient needs and medical documentation, or related experience, or Associate's degree preferably in Nursing with seven years experience in evaluating patient needs and medical documentation, or related experience, required. Registered nurse (RN)designation and current licensure required. Case Management experience and Certified Case Manager (CCM)credentialing required. Three years of Workers' Compensation/Auto medical claims including Utilization Review or Case Management experience, preferred. Five years clinical nurse experience with a preference for previous Orthopedic, Emergency Room, or Critical Care experience preferred. Extensive knowledge of first party and/or third party personal, commercial lines and/or subrogation handling techniques preferred. Willingness to pursue and successfully earn the Associates in Claims (AIC) designation and Certified Nurse Life Care Planner(CNLCP), required. Valid driver's license and good driving record required.

Physical Requirements

Lifting 0-20 lbs; Occasional (<20%)
Lifting 20-50 lbs; Occasional (<20%)
Lifting Over 50 lbs; Occasional (<20%)
Driving; Occasional (<20%)
Pushing/Pulling; Occasional (<20%)
Manual Keying/Data Entry; Occasional (<20%)
Climbing; Rarely


Nearest Major Market: Erie