Workers' Compensation Medical Claims Specialist (PN 20068777) at Ohio Department of Administrative Services

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Full Time

Start Date

Immediate

Expiry Date

22 Jan, 26

Salary

0.0

Posted On

24 Oct, 25

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Claims Examination, Workers' Compensation Laws, Customer Service, Public Relations, English Grammar, Business Communication, Fundamental Mathematics, Interviewing Techniques, Medical Terminology, Medical Diagnosis Coding, Industrial Commission Processes, Microsoft Office, Typing, Data Analysis, Problem Solving, Multitasking, Communication Skills

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 You’ll Be Doing: Performs initial/subsequent claims investigation and determinations for Medical-Only claims within prescribed timeframes. Reviews and gathers information necessary to identify the claim severity. Will staff more complex claims with supervisor, team nurses, and field service office staff. Through phone contacts, written correspondence, and investigation, makes initial and subsequent claim determinations and issues orders as appropriate. Sends Due Process notifications; reviews claim for supporting medical; refers claim for medical review if necessary and issues appropriate BWC orders. Create Case for referral to the Industrial Commission of Ohio for a decision as needed. Processes and maintains claim information, medical and legal documents within prescribed timeframes, and records information in system. Updates and maintains tasks list. Responds orally and in writing to requests from injured workers, employers, providers, legal representatives, managed care organizations, and legislators. Documents claim transactions and activities in claim management system notes and establishes claim tasks for ongoing claim management. 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! To Qualify, You Must Clearly Demonstrate: 3 courses or 9 months training or 9 months experience in English composition or grammar AND 3 courses or 9 months training or 9 months experience in accounting, bookkeeping or general business mathematics AND 3 courses or 9 months training or 9 months experience in communication or public speaking or 9 months experience involving contact with injured workers, employers, legislators, providers or their representatives & public AND successful completion of one typing course or demonstrate ability to type 35 words per minute. -Or 12 months experience 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 months experience 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: workers' compensation laws, policies & procedures*; eligibility criteria & procedures used for processing workers' compensation medical only claims*; principles of customer service; public relations; English grammar & spelling; oral & written business communication; fundamental mathematics (e.g. addition, subtraction, multiplication, division, fractions, decimals & percentages); Workers’ Compensation standard business practices*; interviewing techniques; internet search engines & navigation; medical terminology; medical diagnosis coding*; Industrial Commission processes*; Skill in: operation of a personal computer; typing; use of Microsoft Office software (e.g., Outlook, Word, Excel, Access, PowerPoint); use of BWC-specific software (e.g., Workers’ Compensation claims management system , BWC Web Site, SharePoint)*; operation of office machinery (e.g. calculator, printer, copier, fax, phone); communication skills (e.g., listening, writing, reading, phone etiquette); use of internet; Ability to: define problems, collect data, establish facts, & draw valid conclusions; read, access & understand medical reference manuals & reports; gather, collate & classify information about data, people, or things; communicate effectively and professionally; communicates on sensitive information and inquiries with injured workers, employers, providers or their representatives & the public; multitask by utilizing good organizational skills & time management; answer routine & technical inquiries from injured workers, employers, medical providers & public*; make proper referrals (within agency & external sources)*; diffuse potentially volatile situations; present information to others; work with a team; develop good rapport with internal and external customers; utilize ICD coding tools*; generate properly formatted business correspondence; prioritize caseload based on performance goals*; interpret Data Warehouse reports*. (*) Developed after employment.

Responsibilities

The Workers' Compensation Medical Claims Specialist performs claims investigation and determinations for Medical-Only claims, ensuring compliance with prescribed timeframes. They gather necessary information, communicate with various stakeholders, and maintain accurate claim records.