Med Only Exam/Claims Assistant

Wayne, Pennsylvania

 

PURPOSE OF THE JOB

The purpose of this job is to administer benefits in specified jurisdictions in accordance with statutory and case law as well as pertinent regulations for an inventory comprised of minor injuries with no lost time. This role will provide administrative support and overall assistance to Claims Examiners while providing mentorship and training to junior Claim Assistants. This position exists to reserve, manage, and bring Workers Compensation claims to an equitable conclusion and ensure timely payment of benefits within the company standards, state law, and best practice guidelines.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Receives and reviews information related to Medical Only claims.

  • Communicates via mail, phone, and email with injured workers, employers, and medical providers.
  • Sets up file diaries, documents follow-up care, and other claim-related activities.
  • Assesses reserves appropriately and timely with authority level not to exceed $2,500.
  • Reviews and responds to incoming mail, emails, telephone calls, and fax transmissions from providers and injured workers.

Manages medical treatment to bring files to closure.

  • Moves inventory to closure or upgrades as injuries evolve.
  • Reviews and brings files to supervisors attention when issues become complex.
  • Supports the process by scheduling medical or testing appointments to determine appropriateness of medical care being received related to injury.
  • Authorizes/certifies medical treatment in line with Utilization Review (UR) Regulations and as outlined within department UR plan.
  • Identifies, investigates, and pursues subrogation cases.
  • Follows up with medical providers to obtain results.
  • Maintains effective communications with other departments and maintains a good working relationship with customers.

Pays bills appropriately and timely.

  • Reviews and approves or denies medical bills and returns bills with insufficient information.
  • Processes bills in the bill paying and tracking system or issues for processing by others.
  • Ensures timely payment of bills to ensure treatment continuity.
  • Prepares, schedules and processes benefit and medical payments on claims as directed.
  • Processes non-medical payments.

Delivers intermediate to advanced administrative support to Claims Examiners.

  • Contacts insured or other involved persons to obtain necessary information to process claims.
  • Documents conversations or information to claim file note pad.
  • Stays current with diary tasks.
  • Provides training and mentoring to less-experience Claims Assistants.
  • Ensures documentation required to process claims is accurate and complete for auditing purposes.
  • Assists Claims Examiner with complete post-claims resolution and related administrative projects.

Delivers exceptional customer service to internal and external customers, including insureds.

  • Provides customer service such as giving information to insureds, injured workers or providing referrals to outside vendors as requested by Examiner.
  • Organizes and works with Examiner using computer to enter, access, search and retrieve data.
  • Communicates pertinent claim information to the client, legal counsel, medical and rehab providers as well as internal claims staff.

SUPERVISORY RESPONSIBILITIES

This role does not have supervisory responsibilities.

EDUCATION AND EXPERIENCE

High school diploma or general education degree (GED) or related degree, required. Minimum 3 years of related experience and/or training; or equivalent combination of education and experience.

CERTIFICATES, LICENSES, REGISTRATIONS

Medical Only Examiner Certification preferred.

KNOWLEDGE AND SKILLS

Working knowledge of claims principles and practices. Strong computer typing, data entry, attention to detail and phone skills. Ability to read, write and comprehend simple instructions, short correspondence, and memos. Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization. Ability to read, analyze, and interpret technical journals, financial reports, or legal documents. Ability to respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community. Ability to add, subtract, multiply, and divide using whole numbers, common fractions, and decimals. Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to compute rate, ratio and percent and to draw and interpret bar graphs. Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions.

PHYSICAL REQUIREMENTS

Office environment no specific or unusual physical or environmental demands and employees are regularly required to sit, walk, stand, talk, and hear.

COMPETENCIES

This position maps to the Individual Contributor level. Additional competencies required: None.

WORK ENVIRONMENT

This position operates in an office environment and requires the frequent use of a computer, telephone, copier, and other standard office equipment.

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