Claims Specialist 1, Medical

If you’re passionate about helping people protect what matters most to them, as well as innovating and simplifying processes and operations to provide the best customer value, then Nationwide’s Property and Casualty team could be the place for you!

We are looking for 10 individuals to join the Medical Claims team. Your career at Nationwide begins on Monday, June 27th, 2022 with an award-winning 4-12 week training program that is designed to set you up for success and confidence in your new role.

Base salary for this position can range from $46K-$55K dependent upon experience and location.

Positions are full-time work-from-home and may be filled in the Eastern, Central, Mountain, or Pacific time zones.

WFH (Remote) technology requirements

  • Internet speeds of 30 mbps download and 3 mbps upload
  • Ethernet connection capability between your work equipment and home internet equipment
  • A dedicated space to work and house all the equipment

Schedule: Training is traditional 8-4:30, Monday through Friday; Permanent work schedules will vary based on business demand. We typically need more support for Mountain and Pacific time zones so traditional hours may vary, depending on candidate time zone.

Ideal candidates will have:

  • Strong customer service and organizational skills
  • Self-motivated, willingness to learn, self-sufficient, and focused
  • Medical experience/knowledge is a plus
  • Casualty Claims experience is a plus
  • Bilingual candidates are a plus!

(Internal Use Only) Compensation Grade: D3

Please note that this role may be filled at another level, depending on qualifications and related experience.

Colorado Residents: Email [email protected] for salary information.

Job Description SummaryProviding exceptional customer service and developing productive, trusting relationships with policyholders and claimants allow us to deliver on Nationwide’s promise. Complexity of coverage and the intricacies of medical claims offers variety of work and requires critical thinking and adaptability. If you can empathize, listen and protect confidential information and work collaboratively to resolve and pay claims, we want to hear from you!

As a Claims Specialist I, you’ll investigate and evaluate first-party medical claims – personal injury protection (PIP), medical pay and medical benefits claims – for eligibility, medical necessity, appropriateness of charges and alignment with state fee schedules. You’ll establish relatedness, casualty and appropriateness of treatment based on the compensable injury and make payment decisions according to standard claims methodologies. We’ll count on you to promote and provide outstanding customer service.

Job Description

Key Responsibilities:

  • Pays claims accurately, based on policy provisions, state mandates and/or fee schedules.
  • Initiates and conducts follow-ups via proficient use of claims systems and related business systems
  • Ascertains and initiates appropriate requests for medical and non-medical information needed to accurately pay claims.
  • Determines applicable coverage, medical necessity and applicability of charges related to injury claim.
  • Partners with Special Investigation Unit and National Recovery to identify fraud and subrogation opportunities.
  • Maintains and develops current knowledge of: assigned insurance lines; court decisions which may impact the claim function, current guidelines and policy changes and modifications. This may require attendance at various seminars or training sessions.
  • Reviews and researches medical bills and surgical reports acquired from providers for contestability and pre-existing health history.
  • Submits severe incident reports, reinsurance reports and other information to claims management as needed.
  • Delivers a positive customer service experience to all internal, external, current and prospective Nationwide customers.
  • Communicates regularly with policyholders, agents, providers and field claims representatives through telephone calls, and letters.

May perform other responsibilities as assigned.

Reporting Relationship: Reports to Manager.

Typical Skills and Experiences:

Education: Undergraduate degree or equivalent experience preferred.

Licenses/Designations/Certifications: State licensing where required. Successful completion of required claims certification schools/classes.

Experience: One to three years of customer service and/or claims processing/handling experience preferred.

Knowledge, Abilities and Skills: General knowledge of insurance theory and practices, insurance contracts and their application. Familiarity with claims processing and medical terminology. Familiarity with related standard methodologies and procedures preferred. Confirmed ability to meet customer needs and provide outstanding service by advising customers of the claims process. Strong analytical skills to make decisions and resolve issues in such areas as application of coverages to submitted claims, application of laws of jurisdiction to investigatory facts, application of policy exclusions and exceptions. Able to effectively prioritize work. Validated written and verbal communication skills for contact and/or negotiation with policyholders, claimants, peers, attorneys, physicians, agents and the general public. Ability to efficiently operate personal computer and software for claims-related and other business applications.

Other criteria, including leadership skills, competencies and experiences may take precedence.

Staffing Exceptions to the above must be approved by the hiring manager’s leader and HR Business Partner.

Values: Regularly and consistently demonstrates Nationwide Values.

Job Conditions:

Overtime Eligibility: Eligible (Non Exempt)