Claim Investigator Representative

The Phia Group provides, amongst other things, claim recovery services for health benefit plans. When a health benefit plan pays medical bills, and we later discover someone else should have paid those medical bills, The Phia Group – on behalf of the health plan – will seek to recover the funds. The Case Investigator plays an important role in this effort, by determining whether another proper payer exists, and obtaining the details needed to pursue fund reimbursement.
 

The Claim Investigation Representative is responsible for communicating with plan members (insured participants) to determine potential sources of recovery (i.e. auto insurance, workers compensation, first party coverage, third party coverage, etc.). You will also be in contact with insurance carriers to collect adjuster and claim information while balancing communication with clients (health benefit plan sponsors, employers, and claims administrators) via phone and email.

In addition to helping hard working employees and their families access high quality, affordable health care, while enjoying unrivaled benefits for yourself, you will also enjoy being part of a team that has been recognized by The Boston Globe as a Top Place to Work. In its 14th annual employee-based survey, The Boston Globe determined that The Phia Group is one of the most rewarding, admired and meaningful employment experiences in the Commonwealth of Massachusetts, as voted upon by the people who know them best – their employees.

The Phia Group is committed to fostering, cultivating, and preserving a culture of diversity and inclusion. With this in mind, we always seek to attract and develop candidates who share our passion for the healthcare industry and our commitment to diversity and inclusion. We encourage applicants who share that passion to explore this opportunity to join our dynamic team.

Essential Duties and Responsibilities

• Calling members for accident details
• Maintaining records and notes in an online case management system program
• Drafting, mailing & faxing correspondence
• Calling insurance carriers for claim information (claim #, adjuster name, phone, fax & mailing address)
• Providing clients with accident details, payment ledgers, police reports, etc…
• Reviewing plan documents for possible exclusions Verifying first party, workers’ compensation, third party and/or attorney representation and properly promoting and/or transferring the file to the appropriate CRS
• Acting as the CI’s out of office (checking voicemail messages and emails)
• Will be responsible for consistency and accuracy on time-sensitive documents.
• Managing a large case load (being no more than 10% behind)
• Using MS Word, Excel, Microsoft Outlook and other programs in preparation of correspondence and/or other documents

Experience and Qualifications

• Excellent attention to detail with the ability to multi-task
• Excellent communication skills
• High level of proficiency using Microsoft Word and Excel required
• Outstanding organizational, interpersonal, and administrative skills
• Excellent telephone, writing, and communication skills
• Must be self-motivated and able to meet deadlines under pressure
• Must have the ability to work as part of a team, as well as to work independently

Working Conditions / Physical Demands
Sitting at workstation for prolong periods of time. Extensive computer work. Workstation may be exposed to overhead fluorescent lighting and air conditioning. Fast paced work environment. Operates office equipment including personal computer, copiers, and fax machines.

This job description is not intended to be and should not be construed as an all-inclusive list of all the responsibilities, skills or working conditions associated with the position. While it is intended to accurately reflect the position activities and requirements, the company reserves the right to modify, add or remove duties and assign other duties as necessary.

External and internal applicants, as well as position incumbents who become disabled as defined under the Americans with Disabilities Act, must be able to perform the essential job functions (as listed here) either unaided or with the assistance of a reasonable accommodation to be determined by management on a case by case basis