Toledo - WC Claims Specialist (PN: 20069733)

State of Ohio • Toledo, OH

11d • Hybrid

About The Position

With roughly 1,500 employees in seven offices across Ohio, BWC is the state agency that cares for Ohio workers by promoting a culture of safety at work and at home and ensuring quality medical and pharmacy care is provided to injured workers. For Ohio employers, we provide insurance policies to cover workplace injuries and safety and wellness services to prevent injuries. BWC is a dynamic organization that offers career opportunities across many different disciplines. BWC strives to maintain an inclusive workplace. We begin by being an equal opportunity employer. Employees can participate in and lead employee work groups, participate in on-line forums and learn about how different perspectives can improve leadership skills. Our Vision: To transform BWC into an agile organization driven by customer success. Our Mission: To deliver consistently excellent experiences for each BWC customer every day. Our Core Values: One Agency, Personal Connection, Innovative Leadership, Relentless Excellence. 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.

Requirements

• 36 mos. exp. in position requiring evaluation of medical or public assistance benefits (e.g., health insurance benefits, disability benefits, workers’ compensation benefits, unemployment benefits, public assistance benefits for food subsidies) in order to determine eligibility for benefits, approve or deny claims, resolve benefit-related disputes, calculate benefit payments, &/or perform similar benefit-related duties.
• Completion of undergraduate core coursework in business, humanities, social & behavioral science, education or related field; 12 mos. exp. in position requiring evaluation of medical or public assistance benefits (e.g., health insurance benefits, disability benefits, workers’ compensation benefits, unemployment benefits, public assistance benefits for food subsidies) in order to determine eligibility for benefits, approve or deny claims, resolve benefit-related disputes, calculate benefit payments &/or perform similar benefit-related duties.
• 24 mos. exp. as Workers' Compensation Claims Assistant, 16720 &/or BWC Customer Service Representative, 64451, &/or BWC Employer Service Representative, 63521.
• 12 mos. exp. as Workers' Compensation Medical Claims Specialist, 16721.
• Any combination of at least 36 mos. exp. in position requiring evaluation of medical or public assistance benefits &/or as Workers' Compensation Claims Assistant, 16720, &/or as BWC Customer Service Representative, 64451 &/or as BWC Employer Service Representative, 63521.
• Equivalent of Minimum Class Qualifications For Employment noted above.
• Knowledge of: workers' compensation laws, policies & procedures; eligibility criteria & procedures used for processing workers' compensation claims; English grammar & spelling; oral & written business communication; public relations; addition, subtraction, multiplication, division, fractions, decimals & percentages; interviewing techniques; internet search engines & navigation; medical terminology; medical diagnosis coding; Industrial Commission processes; claims reserving;
• 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, Intrafin, FMS fraud system); 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 & understand medical reference manuals & reports, gather, collate, & classify information about data, people, or things; respond to sensitive inquiries from & contacts with injured workers, employers, providers or their representatives, & the public; 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; use International Classification of Diseases (ICD) coding manuals/system; generate properly formatted business correspondence; read and understand compensation payment plan screens, interpret Cognos reports.

Responsibilities

• Manages a caseload of Workers’ Compensation claims
• Communicates, coordinates & collaborates with internal & external stakeholders (e.g. Disability Management Coordinator [DMC], Medical Service Specialist [MSS], Managed Care Organization [MCO], Employer Management [EM] team, Safety & Hygiene, injured workers, employers, Third Party Administrators [TPA] & rehabilitation personnel) in order to set return to work expectations.
• Performs initial/subsequent claims investigation & determination within prescribed timeframes: Contacts parties involved in claim process; completes investigation during initial claim development to determine information pertinent to management of claim (e.g., jurisdiction, coverage, causality, compensability, claim data accuracy, current work status of claimant, job description, salary continuation, physical demands of job, & work history of claimant).
• Processes various types of compensation ranging from Temporary Total (TT) Compensation, Wage Loss, Permanent Partial and Percentage of Permanent Partial, Living Maintenance, to Lump Sum Advancement requests; addresses subsequent requests by parties to claim via due process notification, investigation, BWC orders & referrals to the Industrial Commission (IC) of Ohio
• Responds to customer inquiries
• Follows Ohio Revised Code and BWC policies and procedures
• Communicates with legal representatives, employers, claimants, etc.

Benefits

• Medical Coverage
• Free Dental, Vision and Basic Life Insurance premiums after completion of eligibility period
• Paid time off, including vacation, personal, sick leave and 11 paid holidays per year
• Childbirth, Adoption, and Foster Care leave
• Education and Development Opportunities (Employee Development Funds, Public Service Loan Forgiveness, and more)
• Public Retirement Systems ( such as OPERS, STRS, SERS, and HPRS ) & Optional Deferred Compensation ( Ohio Deferred Compensation )

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree