Sr. Medical Management Specialist - Erie Insurance

Division or Field Office:

New York Branch Office
Department of Position: Claims Department
Work from:
New York Branch Office Salary Range:
$47,423.00-$75,753.00*

salary range is for thislevel and may vary based on actual level of role hired for

*This range represents a national range and the actual salary will depend on several factors including the scope and complexity of the role and the skills, education, training, credentials, location, and experience of an applicant, as well as level of role for which the successful candidate is hired. Position may be eligible for an annual bonus payment.

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.

Benefits That Go Beyond The Basics

We strive to be Above all in Service® to our customers-and to our employees. That's why Erie Insurance offers you an exceptional benefits package, including:

• Premier health, prescription, dental, and vision benefits for you and your dependents. Coverage begins your first day of work.
• Low contributions to medical and prescription premiums. We currently pay up to 97% of employees' monthly premium costs.
• Pension. We are one of only 13 Fortune 500 companies to offer a traditional pension plan. Full-time employees are vested after five years of service.
• 401(k) with up to 4% contribution match. The 401(k) is offered in addition to the pension.
• Paid time off. Paid vacation, personal days, sick days, bereavement days and parental leave.
• Career development. Including a tuition reimbursement program for higher education and industry designations.

Additional benefits that include company-paid basic life insurance; short-and long-term disability insurance; orthodontic coverage for children and adults; adoption assistance; fertility and infertility coverage; well-being programs; paid volunteer hours for service to your community; and dollar-for-dollar matching of your charitable gifts each year.

Position Summary

Responsible for handling complex medical management claims and litigation portion of first party claims exercising discretion and independent judgement in handling of work.

• This position is being reposted. If you have already applied, you do not need to reapply your application is under review.
• The successful candidate will work from the New York Claims Office. A hybrid schedule may be considered.

Duties and Responsibilities

Handles first party medical benefit claims, including but not limited to: complex coverage, litigation, complex fatalities complex wage loss claims and claims involving suspected fraud.and/or misrepresentation. Evaluates and makes independent decisions regarding coverage. Conducts investigations, determines total value of claims, sets, and maintains adequate reserves, and manages cases.

Handles litigation portion of first party claims, settles within authority as appropriate and works with defense counsel when defending suit on litigation strategy.

Investigates, evaluates, and resolves complex coverage questions for multiple jurisdictions, including claims outside ERIE's footprint in compliance with the appropriate applicable state laws.

Investigates, evaluates and resolves claims with suspected fraud/misrepresentation, including working with ISS, Examiner, Underwriting and counsel as needed,

Prepares related correspondence and reports, obtains medical and employment related records, calculates wage loss claims per applicable state laws and brings claims to conclusion.

Establishes immediate contact with Policyholders, Claimants, Agents, and counsel as necessary.

Reviews claim files on a regular basis and takes necessary follow-up and/or closing action.

Evaluates, processes, and takes appropriate action on claim-related bills and medical, rehabilitation and special investigative reports. Determines claims to be paid, compromised, or contested.

Duties and Responsibilities (cont'd if applicable)

Attends industry-related training programs to stay current on legal developments and ensure compliance with applicable laws and regulations impacting the operation of the department.

Assists or acts on the behalf of supervisor when required, including handling of insurance department complaints.

When appropriate identifies subrogation situations and initiates appropriate action.

Develops expertise in legal and medical terminology and procedures.

Assists in training branch office personnel in related matters.

Assigns, monitors, and controls activities of vendors in a cost-effective manner

The first five 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

Customer Focus

Nimble Learning

Values Diversity

Collaborates

Cultivates Innovation

Decision Quality

Ensures Accountability

Instills Trust

Optimizes Work Processes

Self-Development

Qualifications

Minimum Required Education Equivalents:

High School Diploma or GED and five years of previous Medical Management claims handling experience, or a Bachelor's Degree and three years of previous Medical Management claims handling experience required. Strong working knowledge of applicable state laws required. Strong working knowledge of human anatomy and medical terminology required. Expertise in state no-fault laws and knowledge of civil law required. Successful completion of AIC courses preferred. Working knowledge of medical bill repricing system required.Knowledge of multiple medical management jurisdictions preferred. Appropriate license as required by state.

Physical Requirements

Climbing/accessing heights; Rarely

Driving; Rarely

Lifting/Moving 0-20 lbs; Occasional (
Lifting/Moving 20-50 lbs; Occasional (
Ability to move over 50 lbs using lifting aide equipment; Occasional (
Manual Keying/Data Entry/inputting information/computer use; Often (20-50%)

Pushing/Pulling/moving objects, equipment with wheels; Occasional (

Nearest Major Market: Rochester