Medical Claim Analyst

Under direct supervision, processes medical only claims within authority, processes other claims open only for the administration of medical benefits (i.e.

maintenance claims without actuarial reserves); approves payments and claimant reimbursements on lost time disability claims, within authority, after compensability has been determined.


* College degree or the equivalent education and experience


* Two or more years of experience as a Claim Clerk or the equivalent, demonstrating a thorough knowledge of computer entry and operations.


* Demonstrates a thorough working knowledge of claim processing and claim policies and procedures.


* Demonstrates an understanding of basic medical terminology and appropriate medical tests for claimed conditions


* Demonstrates effective and diplomatic oral and written communication skills.


* Demonstrates a customer-focused approach including the ability to identify and understand customer needs, and interacts effectively with others


* Must be licensed as required by state and local jurisdictions.

Must complete designated continuing education courses while in position in order to advance.

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* Processes "M" Case claims (medical only) within area of payment authority up to, but not exceeding $3,500.


* Processes claims, other than "M" cases, where all issues (indemnity, legal, etc.) have been settled and the claim is only open for payment of medical benefits (i.e.

maintenance claims not requiring actuarial reserves).


* Contacts, by telephone, insureds, claimants, and medical providers for additional information or medical verifications to verify and report the status of claims.


* May verify coverage on claims by following normal coverage confirmation procedures, as requested.

Alerts Team Manager of any errors or discrepancies.


* Reviews and updates data into a computerized system.


* Approves payments of medical bills on lost time disability claims, within payment authority, after compensability has been determined by the Team Manager or claim technician/handler.


* Informs Team Manager of all Workers Compensation "M" Case claims to be removed from the "M" Case classification per Claim Best Practice guidelines.


* Answers routine questions, orally and in writing, from agents, claimants, insureds, or other interested parties.


* Keeps Team Manager informed verbally and in writing of activities and problems within assigned area of responsibility; refers matters beyond limits of authority and expertise to Team Manager for direction.


* Consults with other departments and business units.


* Documents receipt and contents of medical reports.

Reviews and handles other correspondence within authority including material from the team member, customer, or State.


* Processes claims, other than "M" cases, where all medical issues have been settled and the claim is only open for payment of long term Indemnity benefits.


* Identif...