Medical Only Claims Examiner (Workers' Comp)
As a Med Only Claims Examiner at ICW Group, you will administer benefits in accordance with statutory and case law as well as pertinent regulations for an inventory comprised of minor injuries with no lost time. Reserve, manage and bring Workers’ Compensation claims to an equitable conclusion within the company standards and best practices guidelines. Maintain effective communications with other departments and maintains a good working relationship with customers.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Moves inventory to closure or upgrades as injuries evolve.
- Manages medical treatment to bring files to closure.
- Assesses reserves appropriately and timely with authority level not to exceed $2,500.
- Pays bills appropriately and timely.
- 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, document follow-up care and other claim related activities.
- Follows up with medical providers to obtain results.
- 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 Regulations and as outlined within department UR plan.
- Reviews and respond to incoming mail, emails, telephone calls, and fax transmissions from providers and injured workers.
- Takes actions required to respond to mail.
- 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.
- Identifies, investigates, and pursues subrogation cases.
- Responsible for bringing files to supervisor’s attention when issues become complex.
- High school diploma or general education degree (GED).
- Must be state certified within 1 year of handling the Medical Only desk or certification along with 1-3 years insurance experience OR have an equivalent combination of experience and education.
- Excellent verbal and written communication skills, time management and organizational skills.
- Must be detail oriented, team players and have a sense of urgency for execution.
- Excellent phone skills. Strong computer typing skills and data entry experience.
- Attention to detail, ability to multi-task and strong prioritization 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 add, subtract, multiply and divide using whole numbers, common fractions and decimals.
- Ability to compute rate, ratio and percent, and to draw and interpret bar graphs.
- Ability to apply common sense understanding to resolve issues and problems that arise.
- Ability to deal with problems involving several concrete variables in standardized situations.
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