Medical Claims Adjuster

Description:

We are looking for a highly capable Medical Only Claims Adjuster to join our Claims team and work from either our Rockwood, PA, Richmond, VA, or Omaha, NE offices. Alternatively, we can also fill this role in our Springfield, MO office. The position reports to a manager based in Rockwood, PA.

The Medical Only Claims Adjuster is responsible for managing medical-only claims for non‑partnership accounts, primarily within the jurisdictions of Pennsylvania and Maryland. In addition, this position manages both Federal and State Black Lung claims that have already been reviewed and a schedule of benefits approved by the Department of Labor. Under close supervision, this role investigates compensability, conducts claimant, employer, and provider outreach (including required alive‑and‑well checks), sets reserves, denies non‑compensable claims, and ensures appropriate medical payments are made timely and accurately. The position emphasizes strong claim management fundamentals, timely resolution, thorough documentation, and consistent communication with all claim stakeholders

Although Rockwood underwrites general liability insurance and workers’ compensation for many types of businesses, our speciality is underwriting workers’ compensation insurance for the mining industry, with a focus on the coal-mining industry. Rockwood has become a leading underwriter of workers’ compensation for the mining industry by offering workers’ compensation insurance with a commitment to providing the best service on loss control and claims, collaborating across all departments with this common goal. We have never been more committed to our clients to ensure their employees receive excellent medical care if they need it due to a work-related injury or illness. Our passion for outstanding customer focus, combined with our deep industry experience, is what sets up apart from other insurance carriers in this niche market.

Employees in this role are required to accurately record all hours worked and submit timesheets in accordance with company policy. Overtime may be assigned as business needs dictate, and employees are expected to work overtime when required.

This is a 100% in-office position. Candidates must be able to work on-site at a designated company office during standard business hours.

Essential Responsibilities

Under close supervision and guidance, works within narrowly defined limits with an impact on departmental results. This requires conducting thorough claim investigations by interviewing injured workers, insured employers, medical providers, and other relevant parties to determine compensability issues and subrogation potential. 
Manage medical‑only claims for non‑partnership accounts, including Federal and State Black Lung claims that have already been reviewed and a schedule of benefits approved by the Department of Labor. 
Completing required alive‑and‑well checks for Black Lung claims and monitoring of biweekly or monthly benefit payments. 
Resolving issues that are generalized and typically not immediately evident, but typically not complex and within immediate job area. 
Denying any claims that are not covered or do not meet compensability criteria and successfully defending that decision if challenged. 
Actively manage medical only claims to ensure only medical bills appropriate to the claim are paid on a timely basis. 
Managing a diary and completing tasks to ensure that cases are resolved timely and at the right financial outcome. 
Properly setting claim reserves. 
Identifying and directing the assignment and coordination of expertise resources to assist in case resolution. 
Preparing reports for file documentation 
Processing mail and prioritizing workload. 
Responsible for telephone calls from various parties (insured, claimant, etc.). 
Having an appreciation and passion for strong claim management 

Qualifications / Experience Required

An advanced knowledge of medical only workers’ compensation claims typically achieved through: 
High School diploma 
At least six years experience adjudicating medical only claims or in the insurance or healthcare industry (preferably in a commercial claim department) is required, as is familiarity with medical terminology. 
Must have good business acumen (i.e. understand how an insurance company works and makes money, including how this role impacts both Argo Group and our customers’ ability to be profitable). 
A strong focus on execution in getting things done right. Proven ability to consistently produce and deliver expected results to all stakeholders by: 
Finding a way to achieve success through adversity 
Being solution (not problem) focused 
Must have excellent communication skills and the ability to build lasting relationships. 
Exhibit natural and intellectual curiosity in order to consistently explore and consider all options and is not governed by conventional thinking. 
Desire to work in a fast-paced environment. 
Excellent evaluation and strategic skills required. 
Must possess a strong customer focus. 
Effective time management skills and ability to prioritize workload while handling multiple tasks and deadlines.