First Party Medical Claims Adjuster
Are You Driven?® We Are. We are a company of driven, enthusiastic, and determined people. We celebrate achievement and success. We foster innovation, determination, and recognition. Because of that, our employees feel recognized and rewarded for the contributions they make daily. At GAINSCO, it is our people that set us apart. If you are looking for a place where you can make a difference, perceive how your work impacts the company, and be recognized for your efforts and passion, then GAINSCO is the company for you. Why Join GAINSCO? GAINSCO’s work environment rewards engaged individuals who have a desire to contribute and succeed. That’s because our culture encourages individuals to grow their skills as they build their careers. Come join us and become a champion with GAINSCO. As a First Party Medical Claims Adjuster, you’ll be responsible for investigating and resolving first-party medical claims across multiple states. You’ll work closely with policyholders, medical providers, and internal teams to ensure claims are handled accurately, efficiently, and in compliance with state regulations and company guidelines. What does a PIP/MED PAY CLAIMS REPRESENATIVE- MEDICAL MANAGEMENT do at GAINSCO?
- Conduct thorough investigations, including reviewing coverage, taking recorded statements, and gathering supporting documents such as police reports, repair estimates, and medical records.
- Communicate with claimants to explain benefits, eligibility, required forms, and claim procedures.
- Identify and refer potential fraud indicators to the Special Investigations Unit (SIU).
- Evaluate and recommend approval or denial of claims based on policy language, state statutes, and investigative findings.
- Ensure timely and accurate resolution of claims in accordance with company and regulatory standards.
- Review and respond to correspondence and medical bills in a timely manner.
- Maintain accurate and detailed claim files and documentation.
What is required? Education:
- High School Diploma or Equivalent
Licenses/ Certifications:
- To perform the essential functions of this job an active Texas or Florida Adjuster License will be required to comply with state and GAINSCO requirements.
- Upon hire, additional license(s) may be required. If that is the case, license(s) must be obtained.
- All licenses must be maintained in accordance with state requirements.
- Professional Insurance and/or Claims Designations are a plus.
Experience:
- Demonstrated success in customer service capacity.
- Comfortable working in a fast-paced, high-volume call center.
- Experience with 1st Party Medical Claims is preferred.
- Experience with medical coding and/or medical billing a plus.
- Experience with Guidewire, Decision Point, and other claims systems preferred.
Other skills and abilities:
- Strong verbal and written communication skills.
- Excellent attention to detail and organizational skills.
- Ability to manage multiple tasks and prioritize effectively.
- Analytical thinker with the ability to draw conclusions and make sound recommendations.
- Calm and professional demeanor when handling challenging situations.
What else do you need to know?
- Remote
- Excellent benefits package: medical & dental, vision insurance, life insurance, short-term and long-term disability insurance.
- Parental Leave Policy
- 401K + Company Match
- PTO Plan + Paid Company determined Holidays.
- *Applicants are required to be eligible to lawfully work in the U.S. immediately; employer will not sponsor applicants for U.S. work authorization (e.g. H-1B visa) for this opportunity**
All offers are contingent upon a successful background investigation (including employment, education, criminal and DMV verification- when applicable) and a pre-employment drug test with results satisfactory to GAINSCO. GAINSCO is an Equal Employment Opportunity Employer Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor. Apply tot his job Apply To this Job