Senior Claims Resolution Specialist II, No Fault - Michigan Litigation

Michigan No-Fault claims/litigation experience preferred. 

Michigan residency required.

This is a remote position.

Responsible for the investigation, evaluation and disposition of medical cases on assignment, which may include an established portion of the office/team workload and/or individual assigned cases that present moderate to high exposure or complex coverage or liability issues, under limited supervision.  Recognizes and develops countermeasures of problems of larger scope and complexity.

Responsibilities:

• Investigates claims to determine liability, medical necessity, causality. Reviews and verifies coverage and recommends ultimate resolution on assigned cases in excess of their authority to local claims manager and Home Office.  Resolves claims within authority.  Identifies potential suspicious claims or possible third party for subrogation.
• May be considered the office litigation coordinator and responsible for managing the practices and billing activities of outside and in-house counsel.  Accountable for security of financial processing of claims, as well as security information contained in claims files.
• Ensures accurate reserves and settlement authority and adjusts as warranted.  Recommends reserve increases on cases in excess of authority.
• Reviews medical records and bills to verify claimed treatment is causally related to the accident and is reasonable and necessary given facts of the claim.
• Prepares for and attends trials, hearings and conferences and reports to Home Office and local management on status.  Confers with trial counsel and prepares trial reports.
• May assist in the absence of the Claims Team Manager.
• Identifies and refers potentially fraudulent claims to the Special Investigation Unit.
• May represent the company on matters involving state or federal regulatory agencies.
• Recognizes continuous improvement opportunities and develops problem statements and countermeasures for implementation commensurate with the parameters of current assignment.
• May be involved in special projects at the direction of local management.

• Advanced knowledge of coverage, medical, and complex claims handling procedures. Must be knowledgeable of state and federal laws in the jurisdiction in which incumbent operates.
• A full working knowledge of claims operations and procedures is required.
• Strong written and oral communication skills required as well as good interpersonal, analytical and negotiation skills.
• The capabilities, skills and knowledge required is normally acquired through a Bachelor’s degree or equivalent experience and 5-7 years of directly related experience.
• Ability to obtain proper licensing as required.