ABOUT US

Here at Baylor Scott & White Health we promote the well-being of all individuals, families, and communities. Baylor Scott and White is the largest not-for-profit healthcare system in Texas that empowers you to live well.

Our Core Values are:

• We serve faithfully by doing what’s right with a joyful heart.
• We never settle by constantly striving for better.
• We are in it together by supporting one another and those we serve.
• We make an impact by taking initiative and delivering exceptional experience.

JOB SUMMARY

• Under the Safe Choice Claims Manager, the Safe Choice Claims Specialist II reviews, studies, and processes assigned claims within their authority. The goal is to provide prompt, efficient service while protecting the organization’s assets.
• The Claims Specialist II’s main duty involves using discretion and independent judgment on important financial and confidential matters.
• HYBRID position - 2 days onsite each week - Dallas, TX

QUALIFICATIONS

• EDUCATION - H.S. Diploma/GED Equivalent
• EXPERIENCE - 5 Years of Experience

• Promptly investigate assigned non-subscription claims to assess liability and entitlement to benefits.
• Confirm applicable coverage. Maintain compliance with ERISA plan document, insurance policies, and procedure manuals. Take recorded statements. Establish reserve requirements. Identify subrogation potential. Maintain diary.
• Review and evaluate medical and lost wages. Conduct a thorough investigation of the claim by contacting witnesses. Provide status reports to management as needed.
• Resolve complex, severe exposure claims, using high service-oriented file handling.
• Responsibility for the preparation of summaries and files for denials, appeals, medical advice, subrogation, and litigation.
• Collection of documents and summarizing information.
• Providing presentations for committee meetings and any required correspondence.
• Apply technical knowledge and human relations skills to ensure fair and prompt case disposal. Contribute to a reduced loss ratio.
• Assign surveillance on appropriate claims.
• Identifying claims with possible recovery from third parties.
• Maintain communication with doctors, attorneys, safety specialists, nurse specialists, and vendors. Provide prompt, economical, and professional handling of all claims.
• Talking to others to convey information effectively.
• Communicating effectively in writing as appropriate.
• Provide and coordinate training with HR team.
• Work with Claims Manager for improvements in processes to increase proficiency and supervise effective resolution of all claim inquiries.
• Responsible for the approval of lost wages for payroll and for all approvals of medical bills per claim file.
• Pay and process claims within designated authority level.
• Performs other position-appropriate duties as required in a competent, professional, and courteous manner.