Sr. QA Claims Advocate

Published
July 22, 2021
Location
Nationwide, Remote
Category
Job Type

Description

Essential Duties and Responsibilities of Claims Desk, subject to standards of each team or client: 

Coverage:
•    Identify, analyze and confirm coverage.

Customer Service/Contact:
•    Contact appropriate parties and providers to determine liability, compensability, negligence and subrogation potential.
•    Contact appropriate parties to obtain any needed information and explain benefits as appropriate.  Continue contact throughout the life of the file as appropriate.
•    Answer phones, check voice mail regularly, and return calls as needed.
•    Assist with training/mentoring of Claims Adjusters.
•    Assist management when required with projects or leadership as requested.
•    Handle the various duties/responsibilities of the Assistant Unit Manager/Unit Manager as delegated in their absence.

Subrogation:
•    Refer all files identified with subrogation potential to the subrogation department.

Investigation:
•    Verify facts of loss and pertinent claims facts such as employment, wages, or damages and establish disability with treating physicians as appropriate.
•    Identify cases for settlement.  Evaluate claims and request authority no later than 30 days prior to mediation date and negotiate settlement.

•    Evaluate and negotiate liens.
•    Recognize and report potential fraud cases.

Litigation Management:
•    Develop and direct a litigation plan with defense attorney (if assigned), utilizing all defenses and tools to bring the file to closure.  Ensure all filings and state mandated forms are completed timely.  Litigated files must be diaried effectively based on current activity, but no greater than every 60 days.
•    Review claim files involving active litigation on a monthly basis at minimum, and document responses to filings, development of defenses, depositions, and timely referral to defense counsel.
•    Direct the actions of defense counsel on litigated files.
•    Attend mediations and trials as required for cost effective litigation management.

Reserves:
•    Establish ultimate reserves (anticipated cost to bring file to close based on known facts) as soon as practical and monitor to adjust at the time of any exposure changing event.  
•    Pay all known benefits, ensuring they are paid timely on state statute.  
•    Verify all provider bills have been appropriately reviewed and paid within standard timeframes.

Reporting Requirements:
•    Report all serious injuries/liability issues and potential large loss claims to the client and/or reinsurer based upon the criteria provided by the client.
•    Must pass all internal and external audits, which include those performed by regulatory agencies, carriers, and clients.
•    Follow reporting requests as outlined by client files and NARS guidelines.

Resolution:
•    Document plan of action in the claim system and set appropriate diaries.
•    Maintain a regular diary for monitoring and directing medical care, case development, or litigation.
•    Close all files as appropriate in a timely and complete manner.
•    Maintain closing ratio as dictated by management team.

 

Education / Licensing:
•    High School Diploma or equivalent required, 2 year degree or higher preferred.
•    Supervisory experience preferred.

•    Must possess a current Florida Adjusters license and required jurisdictional licensing.


Technical Skills: 
•    Must have a high level of interpersonal skills to handle sensitive and confidential situations and information.
•    Previous negotiation and litigation skills preferred, but not necessary.
•    Must be able to work independently and possess excellent written and verbal communication skills.  
•    Advanced knowledge of a variety of computer software applications in word processing, spreadsheets, database and presentation software. (Microsoft Office platform.)

Abilities:

•    Requires ability to travel when necessary
•    If you live within 25 miles of an office, you will be required to commute and work out of that office.  
•    Requires long periods of sitting
•    Requires working indoors in environmentally controlled conditions
•    Requires lifting of files and boxes up to approximately 20 pounds
•    Repeated use of keyboard, mouse and exposure to computer screen

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