Nationwide Jobs – Claims Specialist II

Job Description:

As a Claims Specialist II, you’ll investigate and evaluate first-party medical, complex personal injury protection (PIP), medical pay and medical benefits claims for eligibility, medical necessity, appropriateness of charges. You’ll determine relatedness, casualty and appropriateness of treatment based on the compensable injury and make payment decisions. We’ll count on you to promote and provide outstanding customer service.

Job Responsibilities:

• Refers complex issues and situations to appropriate claims professional resources.
• Ascertains applicable coverage, medical necessity and appropriateness of charges related to injury claim.
• Partners with SIU and National Recovery to identify fraud and subrogation opportunities.
• Pays claims accurately, based on policy provisions, state mandates and/or fee schedules.
• Identifies potential fraudulent claims and assists Claims Representatives with Special Investigation Unit (SIU) referrals.
• Submits severe incident reports, reinsurance reports and other information to corporate office, Claims management and Underwriting.
• Determines and initiates appropriate requests for medical and non-medical information needed to accurately pay claims.
• Delivers a positive customer service experience to all internal, external, current and prospective Nationwide customers.
• Communicates regularly with policyholders, agents, providers and field claims representatives through phone calls, email and written correspondence.
• Reviews and researches medical bills and surgical reports acquired from providers for contestability and pre-existing health history.

Job Requirements:

• Ability to efficiently operate personal computer and software for claims-related and other business applications.
• Undergraduate degree or equivalent experience. Successful completion of required claims certification schools/courses preferred.
• State licensing where required.
• Other criteria, including leadership skills, competencies and experiences may take precedence.
• General knowledge of insurance theory and practices, insurance contracts and their application.
• Three to five years of customer service and/or claims processing experience preferred.

Job Details:

Company: Nationwide

Vacancy Type:  Full Time

Job Location: New York, NY, US

Application Deadline: N/A

Apply Here

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