Claim Compliance Assistant
The Claim Compliance Assistant is responsible for ensuring compliance in all jurisdictions where MEMIC is licensed. Compliance is met by reviewing claim files and analyzing data to ensure reporting requirements and regulations are administered timely and accurately. The Claim Compliance Assistant will need to communicate with various state agencies, as well as internal partners within the company regarding compliance issues to minimize exposure to the company.
- Assists in state specific compliance reconciliation to ensure form filing is timely and accurate to minimize risk of penalties and fines. Examples of compliance reconciliation are calculation of wage and compensation statements, certified medical bills, MOP/NOC filings and initial indemnity payments, as well as, Maine discontinuance following return to or release for regular duty work.
- Conducts audits on claim files to ensure company is meeting regulatory requirements. Follows up with claims adjusters to rectify any compliance risks and concerns that have been identified through audit.
- Follows up with claims adjusters to rectify any compliance risks and concerns that have been identified through audit.
- Monitors specific areas of concern where compliance risk is high and reports to Claims Unit Manager where there are non-compliance issues.
- Amends benefits paid per mediation, decree or order as stated in statutory requirements to ensure accurate and timely payment to minimize exposure to penalties and fines.
- Assists in Medicare mandatory reporting requirements to ensure timely reporting to federal government on medical benefits or settlement of claims for Medicare beneficiary.
- Works closely with internal and external stakeholders to provide compliance support, feedback and assistance regarding compliance requirements and regulations.
- Conducts Payment Audit Checklist Evaluations (PACE) monthly on closed files for each claims adjuster to ensure indemnity payments and forms are completed accurately.
- Associate Degree or 1-2 years claim handling experience or an equivalent combination of education and work experience.
- A working knowledge of workers’ compensation claim handling procedures and good grasp of workers' compensation fundamentals and the state specific reporting requirements preferred.
- Strong written and verbal communication skills are essential.
- Must have excellent research and comprehension skills and the ability to convert and summarize research data.
- Must be organized and detailed oriented.
- Microsoft Office skills are a must (Word, Excel, Access and PowerPoint).