Medical Claims Examiner

Position Summary:

The Medical Only/Subrogation Claims Examiner exists to provide dedicated operational oversight of Medical Only workers’ compensation claims and subrogation activity administered by Penske’s Third-Party Administrator. The role supports the Workers’ Compensation team by monitoring claim activity, identifying escalation concerns, improving consistency in claim handling, tracking recovery opportunities, and coordinating follow-up with Gallagher Bassett, internal stakeholders, and legal counsel as needed.

This position matters to the business because Penske maintains significant Medical Only claim volume and subrogation exposure. Dedicated oversight is expected to reduce claim leakage, improve escalation timing, strengthen documentation and follow-up, support return-to-work monitoring, and maximize recovery opportunities. Current subrogation metrics reflect approximately 144 subrogation opportunities annually, average annual incurred exposure of approximately $7.75 million, current open subrogation exposure of approximately $22.7 million, a historical recovery rate average of 18.66%, and estimated current recovery potential of approximately $4.2 million.

Major Responsibilities:

- Medical Only Claim Oversight - Monitor and oversee TPA handling of Medical Only workers’ compensation claims; review claim activity for escalation triggers; monitor return-to-work status and modified duty duration; communicate with field management, Human Resources, and internal stakeholders regarding work status concerns and claim progression; review documentation for consistency and completeness; identify red flags and escalate concerns to Workers’ Compensation Examiners or management. Expected result: timely claim progression, earlier escalation of concerns, consistent documentation, and reduced lost-time conversion exposure.

- Subrogation Oversight - Monitor claims for potential subrogation opportunities; review subrogation referrals and recovery evaluations completed by Gallagher Bassett; track statute of limitations exposure and recovery activity; coordinate with Gallagher Bassett subrogation representatives regarding investigations, documentation, and recovery progression; review recovery recommendations and provide observations to Workers’ Compensation Examiners and management; coordinate with legal counsel and internal stakeholders as necessary. Expected result: stronger recovery monitoring, improved follow-up, and reduced risk of missed recovery opportunities.

- Reporting, Auditing & Process Improvement - Maintain accurate documentation and tracking tools; prepare status reports and management updates; assist with development and maintenance of reporting standards and templates; audit claim handling quality; monitor compliance with departmental procedures and claim handling expectations. Expected result: improved visibility, cleaner reporting, and consistent processes across Medical Only and subrogation workflows.

- Meetings & Operational Support - Participate in claim reviews, operational meetings, and strategy discussions; collaborate with Workers’ Compensation Examiners and management on escalated matters; assist with training and communication initiatives as needed; support departmental transition initiatives and operational projects. Expected result: improved team coordination, stronger operational support, and consistent communication with stakeholders.

- Other projects and tasks as assigned.

Qualifications
Qualifications:
- Bachelor's Degree in Business Administration, Risk Management, Insurance, Healthcare Administration, Paralegal Studies, or related field preferred. If no degree, equivalent work experience is required.
- Preferred, not required: workers’ compensation, insurance claims, risk management, paralegal, subrogation, or related claims certifications/designations
- 1-3 years of experience. Workers’ compensation, insurance claims, Medical Only claim handling or -oversight, subrogation coordination, lien review, recovery processes, TPA claim administration, or self-insured workers’ compensation program experience preferred. Equivalent relevant experience may be considered in lieu of degree requirements.
- Intermediate working knowledge of workers’ compensation claim handling principles, Medical Only claim management, escalation indicators, return-to-work monitoring, subrogation and recovery processes, claim documentation review, workers’ compensation terminology, medical documentation, and claim handling expectations. Intermediate proficiency with Access, Risk/FACS, Oracle, Microsoft Excel, Microsoft Teams, Microsoft Outlook, and claims management/reporting tools.
- Ability to identify trends, concerns, escalation indicators, recovery opportunities, operational risks, red flags, inconsistencies, and statute of limitations concerns. Ability to independently review claim information, ask appropriate follow-up questions, evaluate varied claim scenarios, recommend practical solutions, and escalate matters appropriately.
- Strong written and verbal communication skills; ability to communicate effectively with field management, Human Resources, legal counsel, medical providers, TPA representatives, Examiners, management, and senior leadership. Strong collaboration, follow-up, organization, documentation accuracy, prioritization, and attention to detail.
- Regular, predictable, full attendance is an essential function of the job
- Willingness to travel as necessary, work the required schedule, work at the specific location required, complete Penske employment application, submit to a background investigation (to include past employment, education, and criminal history) and drug screening are required.

Physical Requirements:
• The physical and mental demands described here are representative of those that must be met by an associate to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• The associate will be required to: read; communicate verbally and/or in written form; remember and analyze certain information; and remember and understand certain instructions or guidelines.
• While performing the duties of this job, the associate may be required to stand, walk, and sit. The associate is frequently required to use hands to touch, handle, and feel, and to reach with hands and arms. The associate must be able to occasionally lift and/or move up to 25lbs/12kg.
• Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and the ability to adjust focus.

Penske is an Equal Opportunity Employer