Inside Adjuster Analyst II (Medicare)

📋 Description

• • Handle the medical portion of auto accident claims under Personal Injury Protection (PIP) and/or Medical Payment benefits, with some liability claims involving limited policy exposure.
• • Determine coverage eligibility, assess medical bills, and verify reasonableness of charges in alignment with fee schedules and claim guidelines.
• • Investigate potential fraud, duplicate billing, and coverage denials related to Medicare, Medicare Advantage Plans, Medicaid, and other secondary payers.
• • Manage Medicare lien letters and open debt cases, including assessing lien information, determining appropriate actions, and issuing or disputing payments as required.
• • Maintain and update Medicare Section 111 Electronic Reporting to ensure regulatory compliance.
• • Review and analyze medical records, treatment plans, and Independent Medical Examination (IME) results to evaluate necessity and continuity of care.
• • Conduct first-party file processing, including interviewing claimants, witnesses, and medical providers to gather factual information.
• • Summarize claim documentation and enter detailed notes into the claim system, clearly documenting decision-making processes and evaluations.
• • Issue payments to reimburse Medicare, its agents, Medicare Advantage Organizations, and Medicaid in accordance with policy and regulatory requirements.
• • Respond to moderately complex customer communications regarding Medicare/Medicaid coverage, benefits, and claim status with empathy and accuracy.
• • Participate in special projects related to governmental lien resolution and continuous improvement of Medicare claims processes.
• • Prioritize workload independently, manage multiple claims simultaneously, and consistently meet performance, quality, and customer service goals.
• • Maintain compliance with all internal processes, protocols, and licensing requirements, including obtaining an adjuster or appraiser license within 60 days of hire if required by location.
• • Utilize the Medicare Portal and internal systems (e.g., Next-Generation Network) to process claims, track documentation, and report data.
• • Communicate via phone as needed to resolve claim issues, coordinate with providers, and serve customers with compassionate, fast, fair, and easy service.
• • Identify when unique claim circumstances require escalation to design or leadership teams for approval or additional input.
• • Contribute feedback to leadership for process improvements in Medicare lien handling and claims resolution workflows.
• • Work from a dedicated, private home workspace with reliable internet (minimum 50 MB download / 5 MB upload) and approved equipment provided by Allstate.
• • Receive a monthly connectivity reimbursement to offset home internet costs while working remotely.