Makes and maintains a connection with the customer by understanding and meeting their needs; serves the customer with empathy; and follows up to ensure that customer needs have been met.
Reviews customer satisfaction results; recommends, designs, and implements personal and business unit action plans.
Researches and responds to moderately complex customer communications, concerns, conflicts or issues particular to Medicare/Medicaid and other Secondary Payers.
File Documentation and Reporting:
Summarizes documents and enters into claim system notes.
Documents a claim file with notes, evaluations and decision making process.
Issues payments as determined to reimburse Medicare, its agents and entities, Medicare Advantage Organizations, and Medicaid.
Medical Management:
Assesses medical/physical condition and prior injuries of claimant, and obtains and analyzes medical bills, and other related claims to determine reasonableness of charges and relation of injuries to accident, and to ensure compliance with fee schedules, and detect duplicate billing.
Conducts first party file processing/fact gathering, including interviewing claimant, witnesses, medical providers, etc.
Evaluates medical records and treatment plan of claimant and determines if continued treatment is reasonable.
Reviews results of IME (Independent Medical Examination).
Investigates, reviews, and accepts or rejects basic or occasionally moderately complex coverage and other potential coverage; and investigates coverage denial questions.
Determines appropriate benefit for basic and occasionally moderately complex claims, including resolution of basic and occasionally moderately complex usual and customary billings.
Handles specialized claims in moderate to complex situations.
Issue payments as determined to reimburse Medicare, its agents and entities, Medicare Advantage Organizations, and Medicaid.
Medicare Lien Handling:
Reviews correspondence or other lien information and determines the most appropriate course of action to take in response. This includes: Assessing the claim file and other available information sources to determine the best course of action.
Identifying when additional information or evidence to support a decision is needed and creates a plan to obtain that informa
Additional Information
At Allstate, great things happen when our people work together to protect families and their belongings from life's uncertainties. And for more than 90 years, our innovative drive has kept us a step ahead of our customers' evolving needs. From advocating for seat belts, air bags and graduated driving laws, to being an industry leader in pricing sophistication, telematics, and, more recently, device and identity protection.
Job Description
A day in the life of an Inside Adjuster Analyst II, and what it takes to do the job!
At Allstate, great things happen when our people work together to protect families and their belongings from life's uncertainties. And for more than 90 years our innovative drive has kept us a step ahead of our customers' evolving needs. From advocating for seat belts, air bags and graduated driving laws, to being an industry leader in pricing sophistication, telematics, and, more recently, device and identity protection.
The Medicare Adjuster role supports the Medicare Mail Adjusting Team, and is responsible for handling the medical portion of auto accident claims under personal injury protection (PIP) and/or medical payment benefits (and some liability claims), where policy limits or company exposure are limited. The adjuster determines coverage, assesses medical claims and bills, investigates potential fraud, explains coverage, and follows up on ongoing treatments.
The role typically involves handling minor to moderate claims independently, with occasional guidance on more complex cases. The adjuster applies best practice processes to Medicare mail handling, lien resolution, and related correspondence involving Medicare, Medicare Advantage Plans, Medicaid, and other entities. Responsibilities also include verifying policy coverage and limits, determining reserves, and resolving eligible claims. The position involves managing Medicare lien letters, open debt cases, and participating in special projects related to governmental lien resolution.
The adjuster is expected to maintain and update Medicare Section 111 Electronic Reporting and contribute to continuous improvement of Medicare processes. This individual works independently, prioritizes responsibilities, manages workload, and consistently meets performance, quality, and customer service goals, delivering compassionate service that is fast, fair, and easy to ensure customer retention.
Candidates should be comfortable with the possibility of phone communication as part of their duties.
**Candidates for this role must reside in the United States. This position is not available to residents of California, Washington, Alaska, Hawaii and Puerto Rico.
Allstate · - IL (remote)