GENERAL DESCRIPTION

To ensure efficient, cost effective, and high quality delivery of claim management services to injured workers for the Ohio Workers Compensation MCO product line by ensuring EDI requirements are fulfilled, investigating claim allowance, and determining benefits due the injured workers in compliance with BWC, URAC, and company standards. The Claims Specialists primary focus is to manage assigned claims within delegated limited authority controlling costs with focus on an early, safe return to work of Ohios injured workers.

REQUIRED EDUCATION/TRAINING
High School diploma or GED required.
One year administrative experience required.
Knowledge of BWC mandatory and expected EDI transmission elements.
Good oral and written communication skills.
PC literate with knowledge of Microsoft Office products.
Good organizational and time management skills.
Good customer service skills.
Ability to work independently and in a team environment.
Ability to manage multiple and changing priorities.
Decision making and problem solving skills.
Strong analytical and interpretive skills.
Ability to learn rapidly to develop knowledge and understanding of claims practice.
Two (2) years experience handling Ohio Workers Compensation claim adjudication.

ESSENTIAL JOB DUTIES

1. Performs claims management techniques to manage claim to optimal return to work and claim cost outcomes.
2. Analyzes and processes complex or technically difficult claims by investigating and gathering information, managing claims through well-developed action plans to an appropriate and timely resolution.
3. Assist the BWC to determine validity and compensability of the claim.
4. Works to return injured worker to work at the earliest and safest opportunity.
5. Verifies full return to work documentation through telephone and written communication.
6. Participates in managing DoDM and/or MoD programs.
7. Makes referral for case management and/or utilization management in accordance to company guidelines.
8. Ensures medical records are obtained and labeled correctly.
9. Communicates claim activity and processing with the injured worker and the employer, maintaining professional client relationships.
10. Staff claims with RTW barriers and/or claims with increased complexity with TCM.
11. Follows direction of Medical Director.
12. Uses appropriate cost containment techniques (i.e. PPO Network, Vocational Rehab referrals)
13. Review and make determinations on C-9 treatment requests within ODG Guidelines and ensures all parties to the claim have been notified within BWC time constraints.
14. Ensures all time sensitive claim activity is initiated and maintained within company, URAC, and BWC standards.
15. Documents communications in appropriate system(s) and is mindful of the state mandated transparency
16. Responds to BWC inquiries within one business day.
17. Maintains knowledge of BWC rules and laws, workers compensation process, MoD, URAC standards, ODG, and policies and procedures.
18. Serves as a liaison between the IW, EOR, Provider and BWC simultaneously focused on return to work goals and employer retention.
19. Files necessary documentation with BWC and parties to the claim.
20. Manages professional client relationships.
21. Develops and maintains medical knowledge and understanding of clinical practices.
22. Achieves minimal annual training of 10 hours annually measured on a calendar year.
23. May be required to travel up to 25% primarily for employer claim review meetings facilitated by Account Management
24. Additional duties as required

Application Instructions:

In order to provide equal employment and advancement opportunities to all individuals, employment decisions at CorVel will be based on merit, qualifications and abilities. Except where required or permitted by law, employment practices will not be influenced or affected by an applicant's or employee's race, color, religion, sex, national origin, ancestry, citizenship, age, handicap or disability, marital status, medical condition or any other characteristic protected by applicable law. Please be aware that CorVel generally does not review all applications submitted in response to job openings posted on the Internet because of the large volume of responses. Note to Employment Agencies: Please do not forward agency resumes. CorVel Corporation is not responsible for any fees related to unsolicited resumes.