WC Medical Claims Specialist

1 week ago

Columbus, United States Ohio Department of Commerce Full time

BWC is currently operating under a hybrid schedule that may incorporate both teleworking and in-person office hours. Employees must be able to report to the office when requested by management &/or for their initial job training.

What You'll Be Doing:

  • Perform initial\subsequent claims investigation for determination of medical only claims utilizing Workers' Compensation laws, and policy & procedures regarding jurisdiction, coverage, causality, compensability, and claim date accuracy within prescribed time frames.
  • Issue initial orders to Accept, Deny, or Dismiss, Medical Only Claims in addition to Subsequent Determinations through a thorough investigation of all medical and legal evidence available in the claim.
  • Review complex claim issues with team members, supervisor, and nurse; such as subrogation, potential fraud, and interstate jurisdiction.
  • Resolve Data errors identified by internal and external customers in a timely manner.
  • Case manage medical only workplace injury claims.
  • Process requests for claims reactivation and additional conditions.
  • Respond to customer inquiries via telephone, email, written and oral communication.
What our employees have to say:

BWC conducts an internal engagement survey on an annual basis. Some comments from our employees include:
  • BWC has been a great place to work as it has provided opportunities for growth that were lacking in my previous place of work.
  • I have worked at several state agencies and BWC is the best place to work.
  • Best place to work in the state and with a sense of family and support.
  • I love the work culture, helpfulness, and acceptance I've been embraced with at BWC.
  • I continue to be impressed with the career longevity of our employees, their level of dedication to service, pride in their work, and vast experience. It really speaks to our mission and why people join BWC and then retire from BWC .
If you are interested in helping BWC grow, please click this link to read more, and then come back to this job posting to submit your application

At the State of Ohio, we take care of the team that cares for Ohioans. We provide a variety of quality, competitive benefits to eligible full-time and part-time employees*. For a list of all the State of Ohio Benefits, visit our Total Rewards website Our benefits package includes:
  • 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 )
*Benefits eligibility is dependent on a number of factors. The Agency Contact listed above will be able to provide specific benefits information for this position.

Qualifications

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.

-Or 12 mos. exp. as Workers' Compensation Claims Assistant, 16720, (i.e., providing assistance to claims field operations team or medical claims team by ensuring all documents are complete, accurate & in compliance with bureau of workers' compensation procedures, determining allowances using code manual ICD/CPT & taking appropriate action on self-insured claims or referring documents for further action by claims team member, reconstructing lost claim files or assigning claim numbers & updating claim information & managing caseload of self-insured medical & disability claims to ensure compliance with Ohio Workers' Compensation Law).

-Or 12 mos. exp. as BWC Customer Service Representative, 64451, (i.e., providing information/assistance to &/or answering complaints, questions &/or telephone inquiries &/or written correspondence from customers pertaining to claims status or procedures, reviewing & analyzing claims, referring customers to available community services, & conducting telephone interviews with citizens reporting fraud allegations). Note: Classifications may require use of proficiency demonstration to determine minimum class qualifications for employment.

-Or equivalent of Minimum Class Qualifications For Employment noted above.

Job Skills: Claims Examination

Major Worker Characteristics:

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*.

(*) Developed after employment.

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