Medical Management Specialist

Erie Insurance Group; Warrendale (Allegheny County); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Premier health benefits

Pension plan

401(k) with match

Paid time off

Job summary

Erie Insurance Group is seeking a claims professional to handle first-party medical management claims with limited supervision from our Warrendale, PA office. The role involves evaluating coverage, conducting investigations, and determining claim values while maintaining reserves and ensuring timely closures.

The position requires a high school diploma or GED with two years of claims experience, or a bachelor’s degree, and knowledge of state laws, medical terminology, and no-fault rules.

Qualifications

• Requires High School Diploma or GED and two years of general claims handling experience, or a Bachelor’s Degree.
• Strong knowledge of applicable state laws preferred.
• Good knowledge of human anatomy and medical terminology preferred.
• Expertise in state no-fault laws and working knowledge of civil law preferred.
• Working knowledge of medical bill repricing system preferred.

Responsibilities

• Handles medical management claims with limited supervision.
• Work from the Pittsburgh Branch Office in Warrendale, PA; not a work-from-home position.
• Evaluate coverage, conduct investigations, determine claim value, set reserves, and manage cases.
• Prepare correspondence and reports; obtain medical and employment records; calculate wage loss; bring claims to conclusion.
• Coordinate with Home Office on serious or massive injury cases; notify investigations if fraud suspected.
• Assist in litigation as needed and help develop case strategy with counsel.

Skills

Claims handling

Investigation

Communication

Attention to detail

Education

Bachelor’s Degree

High School Diploma or GED

Tools

Medical billing system

ERIE training program

Job description

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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 (State) based on ERIE's geographical differences, 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 6,000 employees and over 13,000 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 among the 2% of Fortune 500 companies to offer a traditional pension plan. Full-time employees are vested after five years of services.
• 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

Within designated authority, handles medical management claims with limited supervision.

• This is NOT a work from home position. The successful candidate will work from the Pittsburgh Branch Office in Warrendale, PA.

Duties and Responsibilities

• Handles first party medical benefit claims, including fatalities and wage loss claims. Evaluates and makes decisions regarding coverage. Conducts investigations, determines total value of claims, sets and maintains adequate reserves, and manages cases.
• Prepares related correspondence and reports, obtains medical and employment related records, calculates wage loss claims per applicable state laws and brings claims to conclusion.
• Investigates, evaluates, and resolves coverage questions in compliance with applicable state laws.
• Establishes immediate contact with Policyholders and Claimants. Contacts Agents 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.
• Coordinates activities with the Home Office on serious or massive injury cases. Notifies company investigative services of cases involving suspected fraud.
• When appropriate manages claims in litigation and assist in the development of case strategy with legal counsel.

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.

Regular and predictable attendance is an essential job function. For certain positions at ERIE, including leadership roles, regular and predictable onsite presence may also be an essential job function based on business and operational needs.

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.

Capabilities

• Values Diversity
• Job-Specific Knowledge
• Self-Development
• Nimble Learning
• Customer Focus
• Ensures Accountability
• Decision Quality

Qualifications

Minimum Educational Requirements

• High School Diploma or GED and two years of general claims handling experience required, or;
• Bachelor’s Degree required.
• OR completion of formal ERIE training program, required.

Additional Experience

• Strong working knowledge of applicable state laws preferred.
• Good working knowledge of human anatomy and medical terminology preferred.
• Expertise in state no-fault laws and working knowledge of civil law preferred.
• Working knowledge of medical bill repricing system preferred.

Designations and/or Licenses

• Successful completion of AIC courses preferred.
• Appropriate license as required by state.
  

Physical Requirements

• Lifting/Moving 0-20 lbs; Occasional (<20%)
• Lifting/Moving 20-50 lbs; Occasional (<20%)
• Ability to move over 50 lbs using lifting aide equipment; Occasional (<20%)
• Driving; Rarely
• Pushing/Pulling/moving objects, equipment with wheels; Occasional (<20%)
• Manual Keying/Data Entry/inputting information/computer use; Often (20-50%)