Nationwide Medical Claims Adjuster in Columbia, Maryland
Nationwide Insurance is hiring a Medical Claims Adjuster to work out of Columbia, MD. Qualified applicants MUST POSSESS a medical background (e.g., nursing, bill coding, medical coding, working in a doctor's office, etc..) and outstanding customer service skills. College Degree PREFERRED. Insurance claims experience is a plus.
JOB SUMMARY: Evaluates complex Personal Injury Protection (PIP), Med Pay, Med Ben claims for eligibility, medical necessity, appropriateness of charges and in accordance with state fee schedules. Determines relatedness, casualty and appropriateness of treatment based on the compensable injury. Makes payment decisions based on policy provisions, state mandates, departmental policies, medical and non-medical information. Promotes and provides "On Your Side" customer service. Evaluates and investigates first party medical claims. Makes payment decisions based on policy provisions, state mandates, departmental policies, medical and non-medical information in accordance with Best Claims Practices.
RELATIONSHIP: Reports to Reports to Claims ManagerDIRECT REPORTS: None
JOB RESPONSIBILITIES:1. Refers complex issues and situations to appropriate claims expert resources.2. Accurately pays claims based on policy provisions, state mandates and/or fee schedules.3. Determines applicable coverage, medical necessity and appropriateness of charges related to injury claim on complex claims.4. Identifies potential fraudulent claims and assists claims representatives with SIU referrals.5. Reviews and researches medical bills and surgical reports obtained from providers for contestability and pre-existing health history.6. Submits severe incident reports, reinsurance reports and other information to home office, claims management, and underwriting.7. Partners with SIU and Subrogation to identify fraud and subrogation opportunities.8. Determines and initiates appropriate requests for medical and non-medical information needed to properly pay claims.9. Delivers a positive On-Your-Side customer service experience to all internal, external, current and prospective Nationwide customers.10. Communicates regularly with policyholders, agents, providers and field claims representatives through telephone calls, and letters.11. Other duties as assigned.JOB REQUIREMENTS:Education: Undergraduate degree or equivalent experience. Successful completion of required claims certification schools/courses preferred.Licenses/Designations: State licensing where required.Experience: Three to Five years customer service and/or claims processing experience preferred.Knowledge: General knowledge of insurance theory and practices, insurance contracts and their application. Familiarity with claims processing, medical billing processes, coding, and medical terminology. Familiarity with related claims best practices and procedures preferred.Skills/Competencies: Proven ability to meet customer needs and provide exemplary service by informing customers of the claims process and ensuring a positive customer experience. Analytical skills necessary to make decisions and resolve conflict in such areas as application of coverages to submitted claims, application of laws of jurisdiction to investigatory facts application of policy exclusions and exceptions. Organizational skills to effectively prioritize work. Proven written and verbal communication skills for contact and/or negotiation with policyholders, claimants, peers, attorneys, physicians, agents and the general public. Ability to efficiently operate personal computer and software for claims-related and other business applications.Values: Regularly and consistently demonstrates the Nationwide Values and Guiding Behaviors.Staffing Exceptions to the above Minimum Job Requirements must be approved by: Business Unit Executive and Human Resources.
JOB CONDITIONS:Working Conditions: Office claims environment. Require ability to sit and operate telephone and personal computer for extended periods of time. Must be willing to work extended hours and to travel with possible overnight requirements. Must be available to work catastrophes (CAT) requiring travel to CAT sites with multiple on-site responsibilities and/or for extended periods of time. Including holidays and week-ends.Credit/Background Check: Due to the fiduciary accountabilities within this job, a valid credit check and/or background check will be required as part of the selection process.ADA: The above statements cover what are generally believed to be principal and essential functions of this job. Specific circumstances may allow or require some people assigned to the job to perform a somewhat different combination of duties.Job Evaluation Activity: Edited 5/2/11 JTG