Provide clerical and technical assistance to Senior Claims Examiners and administer Medical Only claims, ensuring timely processing of claims and payment of benefits, managing and directing medical treatment, and setting reserves.
Principal Duties and Responsibilities
Incumbent must have the skills, ability and judgment to perform the following essential job duties and responsibilities with or without reasonable accommodation:
- Process new claims in compliance with client’s Service Agreement
- Issue all indemnity payments and awards on time
- Process all approved provider bills timely
- Prepare objection letters to providers for medical bills; delayed, denied, lacking reports.
- Answer questions over the phone from medical providers regarding bills
- Contact treating physician for disability status
- Contact employer for return to work status or availability of modified work.
- Contact injured worker at initial set up
- Send DWC notices timely
- Issue SJDB Notices timely
- Request Job Description from Employer
- Handle Medical Only claim files
- Calculate wage statements and adjust disability rates as required
- Keep diary for all delay dates and indemnity payments
- Documents file activity on computer
- Update information on computer, i.e. address changes, etc.
- Schedule appointments for AME, QME evaluations
- Send appointment letters, issue TD/mileage, send medical file
- Schedule interpreter for appointments, depositions, etc.
- Request Employer’s Report, DWC-1, Doctor’s First Report if needed
- Verify mileage and dates of treatment for reimbursement to claimant
- Subpoena records
- File and serve documents on attorneys, WCAB, doctors
- Serve PTP’s with medical file and Duties of Treating Physician (9785)
- Request PD ratings from DEU
- Draft Stipulated Awards and C&R’s
- Submit C&R, Stipulated Awards to WCAB for approval with documentation
- Process checks – stop payment, cancellations, void, journal payments
- Handle telephone calls for examiner as needed
- Complete penalty calculations and prepare penalty worksheets
- Complete MPN,HCO and/or EDI coding
- Complete referrals to investigators
- Complete preparation of documents for overnight delivery
- Work collaboratively with Senior Claims Examiners, Nurse Case Managers and other Assistant Claims Examiners
- Contact with clients, injured workers, attorneys, doctors, vendors and other parties
- Provide updates of claims status to Senior Claims Examiners and Athens management
Essential Job Requirements
The requirements listed below are representative of the knowledge, skill, and/or ability required.
- Bachelor’s degree from an accredited college or university
- Completion of IEA or equivalent courses preferred
- Administrators Certificate from Self-Insurance Plans preferred
- Experienced Indemnity Claims Adjuster Designation preferred
- Knowledge of workers’ compensation laws, policies and procedures
- Understanding of medical and legal terminology
- Well developed verbal and written communication skills
- Strong attention to detail and the ability to research and resolve problems
- Mathematical calculating skills
- Computer processing skills
- Ability to operate standard office equipment
- Ability to work in a paperless environment
- Working knowledge of related information systems, including:
o Microsoft Office (Word and Outlook)
This description portrays in general terms the type and levels of work performed and is not intended to be all-inclusive or represent specific duties of any one incumbent. The knowledge, skills, and abilities may be acquired through a combination of formal schooling, self-education, prior experience, or on-the-job training.
Indeed - 15 months ago