Occ Med Work Injury Claim Specialist

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Serves as the primary point of contact with outside employers and within the clinic on all work injury claims, posting payments and troubleshooting denied claims. Utilizes multiple reports and tools to process aged accounts receivable. Responsible for managing account updates according to insurance remittances. Administers claims submitted and ensures reimbursements are accurate.

Reports to
As Assigned

Education, Experience and Skills Requirements
Post secondary education or equivalent training in a health care or business related field is required; Associates degree preferred. Must have at least 3 years of applicable experience, with previous experience in a healthcare setting preferred. Excellent problem solving skills and oral and written communication skills are required. Strong computer skills and ability to learn a new skill quickly and retain information learned. Past experience working with accounts receivable, medical terminology, coding, accounting principles, data entry, customer service and business procedures are highly preferred.

Licensure/Certification Requirement

Job Specific Competencies
  • Performs research and makes initial evaluations and recommendations for implementation of new procedures, solutions, methods, or improvements. May follow through with implementation.
  • Enters all injury care charges into charge entry and deals directly with physicians on outstanding physician dictation.
  • Communicates internally within the clinic, along with; other service areas, workers compensation, employers and patients to facilitate proper claim processing and payment procedures.
  • Effectively monitors and researches past due accounts. May include performing collection on past due accounts, making outbound calls and working with insurance, employers and patients to resolve any past due payments.
  • Posts payments from workers compensation carriers.
  • Compiles data based on research techniques and on statistical compilations involving an understanding of service area programs, policies, and procedures. Takes independent action to rectify discrepancies, ensuring solutions are considered within a systems context.
  • Demonstrate ability to review, research, submit and monitor claims using specific criteria and requirements. Processes and troubleshoots denied workers compensation claims.
  • Provides assistance to patients, employers and insurance carriers regarding problems or questions with billing or insurance. Submits payment adjustments and performs various complex assignments as assigned.
  • Serves as an expert in a specialized area and is utilized as a resource for others within and outside the service area. Identifies problems and serves as a resource, answering questions, providing guidance, troubleshooting and following up with customers in resolving problems and conflict resolution.
  • Verifies workers compensation, secondary insurance or third party coverage. Coordinates with patients and coworkers alternate forms of payment on denied claims.

Core Competencies
Customer Service
  • Interacts with customers in a warm and friendly way.
  • Takes immediate action to meet customer requests or needs.
  • Listens to understand what customers have to say.
  • Recognizes safety hazards and takes corrective action; seeking assistance when needed.
  • Demonstrates knowledge of operational policies and procedures.
  • Performs work safely, without causing harm or risk to self, others or property.
System Behavior
  • Makes a decision considering the impact of the decision on other areas.
  • Initiates collaboration with others outside of service area.
  • Demonstrates personal commitment to the principles, values, and ethics of the organization.
  • Models accountability for learning by sharing knowledge and learning from others.
  • Builds effective working relationships.
  • Expresses appreciation to others for their work.
  • Treats others with respect.

Leadership Competencies
  • Demonstrates both knowledge and application of Sanford policies, procedures, and guidelines.
  • Demonstrates the ability to take charge, take unpopular stands if necessary, face difficult situations, and is looked to for direction from others.
  • Facilitates and supports change within the Sanford Health.
  • Demonstrates commitment to continuous learning for themselves and staff.

Information Management Competencies
  • Demonstrates skill in accessing, preparing and using information as relevant to position.
  • Verbalizes and demonstrates knowledge of procedures for maintaining security, confidentiality and integrity of employee, patient, family and other medical information.
  • Demonstrates ability to collect, analyze and present data as appropriate to position.

Equipment Competencies
  • Demonstrates skill in use of equipment relevant to position; verbalizes knowledge of appropriate safety procedures.
  • Diagnoses equipment problems; fixes or seeks out someone to fix.
  • Consistently informs appropriate person of problems encountered with repairs or calibration of equipment.

Blood Exposure
  • This position is classified as a Category III position under OSHA guidelines with no risk of exposure to bloodborne pathogens and other potentially infectious materials.


Physical Requirements:
View Physical Requirements

Sanford Health - 15 months ago - save job - block