WC Medical Claims Specialist (PN: 20068751)

State of Ohio • Columbus, OH

22h • Hybrid

About The Position

The State of Ohio, Bureau of Workers' Compensation (BWC) is seeking a WC Medical Claims Specialist to join their team. This role involves performing initial and subsequent claims investigations and determinations for Medical-Only claims within prescribed timeframes. The specialist will review and gather information to identify claim severity, staff more complex claims with supervisors and other teams, and make initial and subsequent claim determinations through phone contacts, written correspondence, and investigation. The position also involves issuing orders, sending Due Process notifications, reviewing claims for supporting medical documentation, referring claims for medical review, and issuing appropriate BWC orders. Additionally, the specialist will create cases for referral to the Industrial Commission of Ohio, process and maintain claim information, medical and legal documents, and update task lists. The role requires responding to requests from various stakeholders, documenting claim transactions, and establishing claim tasks for ongoing management. BWC is committed to promoting a culture of safety, ensuring quality medical and pharmacy care for injured workers, and providing insurance policies and safety services to Ohio employers. The agency strives to be an agile organization driven by customer success, with a mission to deliver consistently excellent experiences.

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 noted above.
• 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

• Claims Examination

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.
• Create 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: High school or GED
• Number of Employees: 101-250 employees