Claims Examiner

Summary: Non-case management staff responsible for supporting the case management process. Always works under direct supervision of a Nurse Case Manager and does not make clinical judgment.

We offer employees a range of perks including but not limited to:

• Competitive Pay
• Health, dental, vision, and life insurance
• Additional insurance options: Critical Illness, Long Term, Short Term Disability, Accidental Death and Dismemberment, Employee Assistance Program, Legal Shield
• 401(k) savings plan with match after 1 year
• Continuous professional training and development
• 8 Paid Holidays
• Paid Vacation and PTO available
• A paid day off for your birthday and work anniversary
• Employee focused culture with appreciation events all year

Primary Responsibilities:

• Establish a three-point contact between the injured worker, employer and provide to gather information needed to file a claim with the Ohio BWC
• Communication and collaboration with injured workers (IW), employers, providers, third party administrators (TPA), attorneys, and the BWC to obtain a safe return to work (RTW) while working within BWC designated guidelines.
• Effectively apply the MCO process including completion of appropriate first report of injury documentation, medical management templates, documentation of potential barriers to a successful RTW within the scope of the non-clinical position.
• Process all Treatment Requests (C-9s) within 72 hours to provide the IW with the treatment medically necessary and appropriate for the Allowed Conditions. Staff C-9 requests with the Nurse Case Manager, or Medical Director as needed.
• Follow up with providers to obtain current treatment plans, results of diagnostics and RTW goals. Obtain modified duty availability from employers and communicate to providers and IWs. Obtain restrictions to a full RTW from provider and communicate to the employer and IW.
• Properly refer all cases to the Nurse Case Manager when appropriate as well as utilize the RN for all clinical issues pertaining to the IW's claims. Identify IWs who are potential vocational rehabilitation candidates and complete the referral process.
• Adherence to all Health Management Solutions (HMS) policies and URAC standards as well as all Confidentiality policies and guidelines. Ensure that all documentation is current, accurate and complete including remaining current with all diaries. Follow all HMS and BWC guidelines for appropriate medical management of claims and participate in educational and informational seminars as needed.
• Completion of team peer-to-peer FROI/CE audits, quarterly.
• Other duties as assigned.

Qualifications:

• High School Diploma/GED
• 2 years of MCO experience preferred
• Exceptional written, telephonic, and oral communication (public speaking), leadership, problem-solving, interpersonal, and organizational skills required. Ability to coordinate and organize multiple priorities.
• Excellent knowledge of medical terminology
• Experience using Microsoft Office programs, especially Excel, Word, PowerPoint, and Access.