WC Medical Claims Specialist (PN: 20068759)

State of Ohio • Columbus, OH

23h • Hybrid

About The Position

The State of Ohio is a drug-free workplace. This position may be subject to additional restrictions pursuant to the State of Ohio Drug-Free Workplace Policy (HR-39). Ohio is a Disability Inclusion State and strives to be a model employer of individuals with disabilities, committed to providing access and inclusion and reasonable accommodation in its services, activities, programs and employment opportunities in accordance with the Americans with Disabilities Act (ADA) and other applicable laws. The Bureau of Workers' Compensation (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, BWC provides 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 and strives to maintain an inclusive workplace. Our vision is to transform BWC into an agile organization driven by customer success, and our mission is to deliver consistently excellent experiences for each BWC customer every day. Our core values are One Agency, Personal Connection, Innovative Leadership, and Relentless Excellence.

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.
• OR 12 mos. exp. as Workers' Compensation Claims Assistant, 16720
• OR 12 mos. exp. as BWC Customer Service Representative, 64451
• 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.

Nice To Haves

• Proficiency demonstration may be required to determine minimum class qualifications for employment.

Responsibilities

• Performs initial/subsequent claims investigation and determinations for Medical-Only claims within prescribed timeframes.
• Reviews and gathers information necessary to identify the claim severity.
• Staffs 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.
• Creates 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 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.

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: No Education Listed
• Number of Employees: 101-250 employees