Cambridge - WC Claims Specialist (PN: 20069710 & 20068446)

Ohio Department of Administrative Services • Cambridge, OH

16h • Onsite

About The Position

This position manages a caseload of Workers’ Compensation claims, requiring communication, coordination, and collaboration with internal and external stakeholders to set return-to-work expectations. The role involves performing initial and subsequent claims investigations and determinations within prescribed timeframes, processing various types of compensation, and responding to customer inquiries while adhering to Ohio Revised Code and BWC policies and procedures. The position also requires communication with legal representatives, employers, and claimants.

Requirements

• 36 mos. exp. working in private insurance organization as claims representative or equivalent position; successful completion of one typing course or demonstrate ability to type 35 words per minute.
• Completion of undergraduate core coursework in business, humanities, social & behavioral science, education or related field; successful completion of one typing course or demonstrate ability to type 35 words per minute.
• 24 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).
• 24 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) &/or as BWC Employer Service Representative, 63521, (i.e., providing information & assistance &/or responding to complaints, questions & inquiries from customers regarding workers’ compensation coverage, established binder/applications maintenance, demographics, supplemental & legal entities, manual classifications, debits/credits & payroll reports &/or various BWC programs & research & explain employer refunds, attorney general balances, payments made to policies &/or divided credits).
• 12 mos. exp. as Workers' Compensation Medical Claims Specialist, 16721 (i.e., managing caseload of medical-only claims & paying medical claims for Ohio Bureau Of Workers' Compensation).
• Any combination of at least 36 mos. exp. working in private insurance organization as claims representative or equivalent position &/or as Workers' Compensation Claims Assistant, 16720 &/or as Workers' Customer Service Representative, 64451 &/or as Workers’ Compensation Employer Service Representative, 63521.
• Equivalent of Minimum Class Qualifications For Employment noted above. Note: Classification may require use of proficiency demonstration to determine minimum class qualifications for employment.
• Claims Examination
• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees