Columbus - WC Medical Claims Specialist - PN: 20068287 at Ohio Department of Administrative Services

Columbus, Ohio, United States -

Full Time

Start Date

Immediate

Expiry Date

26 Jun, 26

Salary

0.0

Posted On

28 Mar, 26

Experience

0 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Medicare Subrogation Claims, Conditional Payment Summaries Review, Processing Payments, Dispute Preparation, Appeal Preparation, Professional Written Communication, Policy Citation, Evidence Organization, Case Activity Tracking, CoreSuite Medicare Tracker, Open Debt Reports Monitoring, Organizational Skills, Multitasking, Time Management, Accurate Documentation, Claims Examination

Industry

Government Administration

Description

BWC’s core hours of operation are Monday-Friday from 8:00am to 5:00pm, however, daily start/end times may vary based on operational need across BWC departments. Most positions perform work on-site at one of BWC’s seven offices across the state. BWC offers flex-time work schedules that allow an employee to start the day as early as 7:00am or as late as 8:30am. Flex-time schedules are based on operational need and require supervisor approval. What Our Employees Have to Say: BWC conducts an internal engagement survey on an annual basis. Some comments from our employees include: BWC has been a great place to work as it has provided opportunities for growth that were lacking in my previous place of work. I have worked at several state agencies and BWC is the best place to work. Best place to work in the state and with a sense of family and support. I love the work culture, helpfulness, and acceptance I've been embraced with at BWC. I continue to be impressed with the career longevity of our employees, their level of dedication to service, pride in their work, and vast experience. It really speaks to our mission and why people join BWC and then retire from BWC. If you are interested in helping BWC grow, please click this link to read more, and then come back to this job posting to submit your application! What You’ll Be Doing: Manage Medicare medical subrogation claims, including reviewing Center for Medicare/Medicaid (CMS) conditional payment summaries, determining relatedness to workers’ compensation injuries, processing payments, and preparing disputes or appeals. Strong communication skills, including professional written communication drafting persuasive disputes/appeals and formal correspondence that clearly establish claim payment disqualification, citing applicable policy (e.g., BWC policies), and organize supporting evidence (remits, checks, medical records) into comprehensive, professional packets. Track, update, and maintain case activity in CoreSuite Medicare Tracker, monitor Open Debt Reports, and follow up with Medicare contractors on errors, re-openings, or updates. Organizational and multitasking skills, including prioritizing work, tracking case actions, time management, and maintaining accurate documentation 3 courses or 9 mos. trg. or 9 mos. exp. in English composition or grammar; 3 courses or 9 mos. trg. or 9 mos. exp. in accounting, bookkeeping or general business mathematics; 3 courses or 9 mos. trg. or 9 mos. exp. in communication or public speaking or 9 mos. exp. involving contact with injured workers, employers, legislators, providers or their representatives & public; successful completion of one typing course or demonstrate ability to type 35 words per minute. -Or 12 mos. exp. as Workers' Compensation Claims Assistant, 16720, (i.e., providing assistance to claims field operations team or medical claims team by ensuring all documents are complete, accurate & in compliance with bureau of workers' compensation procedures, determining allowances using code manual ICD/CPT & taking appropriate action on self-insured claims or referring documents for further action by claims team member, reconstructing lost claim files or assigning claim numbers & updating claim information & managing caseload of self-insured medical & disability claims to ensure compliance with Ohio Workers' Compensation Law). -Or 12 mos. exp. as BWC Customer Service Representative, 64451, (i.e., providing information/assistance to &/or answering complaints, questions &/or telephone inquiries &/or written correspondence from customers pertaining to claims status or procedures, reviewing & analyzing claims, referring customers to available community services, & conducting telephone interviews with citizens reporting fraud allegations). Note: Classifications may require use of proficiency demonstration to determine minimum class qualifications for employment. -Or equivalent of Minimum Class Qualifications For Employment noted above. Job Skills: Claims Examination Major Worker Characteristics: Knowledge of: (1)Workers’ Compensation policies & procedures & laws & regulations governing adjudication & management of medical claims*, (2)Ohio Revised Code*, (3)eligibility criteria & workers’ compensation processing procedures*, (4) Medical Services & Medical Billing & Adjustments policies & standard operating procedures*, (5*) Medicare Secondary Payer Act* (5*6)oral & written business communication, (7)English grammar & spelling, (8)public relations, (9)principles of customer service, (10)addition, subtraction, multiplication, division, fractions, decimals & percentages, (11)standard business practices, (12)medical terminology*, (13)medical diagnosis coding*, (14)Industrial Commission processes*, (15)CAM edits & explanations of benefit*. Skill in: (1)operation of personal computer & peripherals (e.g. printer, fax, scanner, copier), (2)use of Microsoft Office products (e.g., Word, Access, Excel, Outlook), (3)use of BWC-specific software (e.g., Hyland OnBase, CoreSuite, CAM, OHIO.BWC.gov, COR,)*, (4)communication skills (e.g., listening, writing, reading, phone etiquette)*, (5)use of internet search engines & navigation*, (6)se of calculator*, (7)use of 10-key*. Ability to: (1)communicate (written or oral) professionally with injured workers, employers, MCOs, legislators, providers & their representatives & the public, (2)deal with many variables & determine specific action, (3)read & understand technical reference manuals (e.g., MCO policy reference guide), (4)define problems, collect data, establish facts & draw valid conclusions, (5)write clear, concise & professional correspondence & reports, (6) assess questions & provide appropriate referral or information, (7)develop good rapport with internal & external customers, (8)gather, collate & classify information about data, people or things, (9)respond to sensitive inquiries from & contacts with injured workers, employers, health care professionals, (10)multitask by utilizing good organizational skills & time management, (11)make proper referrals (within agency & external sources), (12) work as a team, (13)prioritize workload based on performance goals, (14)interpret data warehouse reports*.

Responsibilities

The role involves managing Medicare medical subrogation claims by reviewing CMS conditional payment summaries, determining injury relatedness, processing payments, and preparing necessary disputes or appeals. This requires strong written communication skills to draft persuasive correspondence and organize supporting evidence into professional packets.