WC Medical Claims Specialist (PN: 20068751)

Ohio Department of Administrative Services • Columbus, OH

12h • Onsite

About The Position

The Bureau of Workers' Compensation (BWC) is seeking a WC Medical Claims Specialist. BWC's core hours of operation are Monday-Friday from 8:00 am to 5:00 pm, with potential variations based on operational needs. Most positions are on-site, but BWC offers flex-time schedules with supervisor approval. Employees have reported positive experiences at BWC, highlighting opportunities for growth, a supportive work culture, and career longevity.

Requirements

• 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.
• 12 mos. exp. as Workers' Compensation Claims Assistant, 16720
• 12 mos. exp. as BWC Customer Service Representative, 64451
• Equivalent of Minimum Class Qualifications For Employment
• Knowledge of workers' compensation laws, policies & procedures
• Knowledge of eligibility criteria & procedures used for processing workers' compensation medical only claims
• Knowledge of principles of customer service
• Knowledge of public relations
• Knowledge of English grammar & spelling
• Knowledge of oral & written business communication
• Knowledge of fundamental mathematics (e.g. addition, subtraction, multiplication, division, fractions, decimals & percentages)
• Knowledge of Workers’ Compensation standard business practices
• Knowledge of interviewing techniques
• Knowledge of internet search engines & navigation
• Knowledge of medical terminology
• Knowledge of medical diagnosis coding
• Knowledge of Industrial Commission processes
• Skill in operation of a personal computer
• Skill in typing
• Skill in use of Microsoft Office software (e.g., Outlook, Word, Excel, Access, PowerPoint)
• Skill in use of BWC-specific software (e.g., Workers’ Compensation claims management system , BWC Web Site, SharePoint)
• Skill in operation of office machinery (e.g. calculator, printer, copier, fax, phone)
• Skill in communication (e.g., listening, writing, reading, phone etiquette)
• Skill in use of internet
• Ability to define problems, collect data, establish facts, & draw valid conclusions
• Ability to read, access & understand medical reference manuals & reports
• Ability to gather, collate & classify information about data, people, or things
• Ability to communicate effectively and professionally
• Ability to communicate on sensitive information and inquiries with injured workers, employers, providers or their representatives & the public
• Ability to multitask by utilizing good organizational skills & time management
• Ability to answer routine & technical inquiries from injured workers, employers, medical providers & public
• Ability to make proper referrals (within agency & external sources)
• Ability to diffuse potentially volatile situations
• Ability to present information to others
• Ability to work with a team
• Ability to develop good rapport with internal and external customers
• Ability to utilize ICD coding tools
• Ability to generate properly formatted business correspondence
• Ability to prioritize caseload based on performance goals
• Ability to interpret Data Warehouse reports

Responsibilities

• Performs initial/subsequent claims investigation and determinations for Medical-Only claims within prescribed timeframes.
• Reviews and gathers information necessary to identify claim severity, and staffs more complex claims with supervisors, team nurses, and field service office staff.
• Makes initial and subsequent claim determinations and issues orders through phone contacts, written correspondence, and investigation.
• Sends Due Process notifications, reviews claims for supporting medical documentation, refers claims for medical review if necessary, and issues appropriate BWC orders.
• Creates cases 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 the system.
• Updates tasks lists and 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 This Job Offers

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