The salary range for this job posting is $55,132.00 - $88,210.00 annually + bonus + benefits
The above represents the salary range for this job requisition. Ultimately, in determining your pay and job title, we'll consider your location, education, experience, and other job-related factors. Your recruiter can share more information about the specific salary range during the hiring process.

Encova Insurance has an immediate opening for a Senior Medical Specialist with experience handling Michigan personal injury protection claims and Michigan Catastrophic Claims Commission reporting. This is a home-based position but you must reside in one of our eligible payroll states as listed on our careers page.

Are you a Referral?

If you know a current Encova Insurance associate and would like to apply as a referral, please encourage them to submit your referral information before you submit your application. You will receive an email with a direct URL link to the Job Posting of interest. Applying through this URL link will create your referral relationship for our Talent Acquisition Team.

Unique residence requirements are listed in each job posting, please review closely for details.

Encova is only able to employ associates who reside and work within specific U.S. states. Our current policies are based on the laws in states in which we are registered for payroll. Our current footprint includes:

Connecticut, Delaware, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nebraska, New Hampshire, New Jersey, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, West Virginia, Wisconsin.

JOB OBJECTIVE:

Investigate, evaluate and process medical claims within established best practices and applicable jurisdictional guidelines.

ESSENTIAL FUNCTIONS:

• Handle medical claims including medical payments both first and third party, PIP, no-fault and first party benefits, and any supplementary coverage such as wage loss, essential services and funeral benefits.
• Review and analyze coverage (including complex coverage issues), apply policy conditions, provisions, exclusions and endorsements, and confirm priority of coverage. Verify the benefits available and the applicable limits and address proper application of any deductibles and co-insurance. When necessary, retain and work with coverage counsel.
• Investigate and gather information, including taking statements as necessary, to determine the facts of loss and subrogation potential.
• Proactively manage and continuously evaluate medical treatment based on the nature and extent of injury. Recognize causality, medical necessity and over-utilization issues. Conduct a medical history investigation as necessary.
• Determine and continually evaluate appropriate reserves.
• Establish a plan of action and utilize appropriate resources as necessary to move the file towards resolution. Investigate and close an average of at least 60 losses per month.
• Communicate with all stakeholders clearly, accurately and professionally.
• Comply with Encova's claims organization policies, established best practices and jurisdictional guidelines.
• Complete necessary reports and authorization requests.
• Maintain competency in the use of multiple claims systems and manage efficient and effective follow-up practices.
• Obtain state licensing as required.
• Serve as a member of claims and other company integrated teams as assigned.
• Recognize when additional claim exposures need to be opened and take appropriate steps to do so.
• Serve as a subject matter expert within Claims as well as other areas of the company.

OTHER FUNCTIONS:

• Maintain an ongoing understanding of claims processes and procedures, and keep current on fair claims practices laws, compliance issues, and business-related developments.
• Maintain open lines of communications with all stakeholders including claims resolution specialists that may be involved in the handling of other elements of the file.
• Attend seminars and workshops as required.
• Perform other duties as assigned.
• Make limited outside contacts at the direction of the team lead.

KNOWLEDGE. SKILLS AND EXPERIENCE:

• This position requires a minimum of 10 years' experience as a claims resolution specialist or equivalent experience in the insurance industry or health care field.
• Desirable candidates will possess at least five years' experience handling Michigan personal injury protection claims and Michigan Catastrophic Claims Commission reporting.
• The candidate must actively demonstrate the skills and abilities listed in the medical specialist job description.
• This position requires strong knowledge of all first party medical policies and coverages in Encova's operating area.
• This position requires strong knowledge of state laws involving first and third-party medical policies and coverages.
• The candidate must have strong knowledge of medical terms and treatments.
• The candidate must be able to process a large volume of documents timely and efficiently.
• The candidate should exhibit strong investigative and organizational skills and the ability to work independently.
• This position requires a college degree or equivalent, and a strong understanding of insurance and the claims organization.
• Continuing insurance education is strongly preferred and may be obtained through The Institutes (Associate in Claims (AIC) and/or Chartered Property Casualty Underwriter (CPCU) designations) or other accredited insurance education provider.

This position has been evaluated in accordance with the Americans with Disabilities Act. Encova Insurance makes every effort to reasonably accommodate disabilities to permit performance of the essential functions and candidates who need such accommodation are encouraged to seek it. This description reflects the nature and level of work performed by associates in this position. It is not an all-inclusive inventory of duties, responsibilities and qualifications required. It provides an accurate overview of the work and skills needed to perform this position. Because job content may change from time to time, Encova Insurance reserves the right to add and/or delete functions from this job as it deems necessary for business reasons.

Ready to join our team?
At Encova Insurance, we firmly believe that our associates drive our company's success by delivering unrivaled service to our customers. With success in mind, we make an ongoing effort to provide an environment that offers challenging, stimulating and financially rewarding opportunities.

Join us to discover a work experience where your diverse ideas will be met with enthusiasm - where you can learn and grow to your fullest potential.

What you can expect from us
Join our family of industry leaders, and let us reward you with a competitive salary, bonus and benefits package that includes but is not limited to: a 401(k), wellness programs, bonus incentive plans and flexible schedules, with an early close of the office every Friday. Additionally, Encova aspires to be an outstanding corporate citizen in all the markets we serve; we encourage and support associate participation in community initiatives through our foundations.

Encova Insurance is an EOE/E-Verify employer.