Medical Claims Review Manager jobs in Lorain, OH

General Summary: Leads and manages a unit of Inside Claim Representatives responsible for investigating, processing, and resolving claims. Assigns work, resolves problems, and performs standard supervisory activities.

Essential Functions:

1. Assesses volume and nature of claims to be processed and provides direction on new losses to claim representatives as appropriate.

2. Serves as a Unit resource for answering questions about complex claims, appropriate procedures, authorities, and the like.

3. Audits claim files regularly for accuracy and corrects any ongoing problems. Provides feedback to staff.

4. Assists in the training and orientation of new Claim Representatives.

5. Interviews, hires, trains, evaluates performance, disciplines, and terminates employment as necessary, within the guidelines established by Human Resources. Resolves conflict, counsels associates, and provides for continued training and development.

6. Maintains a regular diary system and reviews system reports to identify claims to review for quality and regulatory compliance.

7. Keeps apprised of current trends in the industry and related changes in the law; reads trade journals and attends related seminars and workshops.

8. Responsible for development and training of all claims associates under their direction.

9. Develops agency relations through visits, being available to answer questions, and keep agents advised of claim-related changes.

10. Acts as a back-up for other Unit Managers while they are unavailable.

10. Performs other duties as assigned.

Marginal Functions:

1. Fields phone calls and questions from insureds, claimants, agents, and other interested parties.

2. Performs various administrative activities, such as reviewing, preparing, and running reports, preparing follow-up letters to insureds regarding coverage, and attending agency meetings and functions.

3. Reviews and approves expense accounts.

4. Assists in managing AMD Unit vendors.

Minimum Qualifications:

1. College degree or equivalent work experience.

2. Consistently a proven leader with demonstrated high performance and/or previous Senior

Claim Representative experience.

3. Overall knowledge of claims department operations and property and casualty insurance principles in general.

4. Understanding of litigation process and medical terminology.

5. Ability and skills to perform investigations or evaluations.

6. Strong interpersonal skills for dealing with other associates, agents, insureds, and numerous other outside contacts.

7. Strong analytical, organizational, and critical thinking skills.

8. Strong leadership skills.

9. Active in insurance-related studies such as AIC, SCLA, CPCU, etc.

10. Obtains Adjuster licenses that are required for claim handling in states where we write business.

Working Conditions:

• Normal office working conditions
• Sitting for extended periods of time
• Stress associated with meeting deadlines, handling difficult situations, and balancing multiple responsibilities.
• Periodic travel for agency visits, trials and mediations

Supervision Received:

Limited supervision with choice in selection, development and coordination of methods to use; may occasionally develop own methods to perform work.

Supervision Exercised:

Management of claims unit includes the ability to hire, promote, and terminate. Evaluates performance, and is responsible for the continued training and development of assigned staff.