Claims Pmt & Compl Spec I - AR

SUMMARY:

Performs advanced technical duties which includes analyisis of wage data to calculate average weekly wage and compensation rates, determination of compensation owed for all benefit types and issuance of said compensation checks for all benefit types from proper reserve categories. Responsible for the determination of amounts owed to all parties for settlements and the issuance of said settlement checks from proper reserve categories. Filing required initial and subsequent jurisdictional filings via EDI, paper, and State Websites. Resolution of EDI FROI and SROI errrors. Issuance of miscellaneous payments, legal payments and manual payments, processing of refunds and transfers, posting manual payments. Contacts include agents, policyholders, claimants, attorneys, and other Claims staff. If requested, contacts employers to obtain missing wage information or to clarify information submitted.

PRIMARY RESPONSIBILITIES: 

· Review payment requests to ensure compliance with the Workers Compensation regulations.

· Analyze wage data and calculate average weekly wage and compensation rates.

· Contacts policyholders for payment and/or wage data clarification and to obtain necessary information.

· Verifies, calculates, and pays approved injured worker travel and miscellaneous expenses for all jurisdictions.

· Determines compensation owed for all benefit payment types and issues benefit checks accordingly from proper reserve categories.

· Determines compensation owed for compromise payments, dual wage earning, 70% appeal payments, supplemental benefits and issues benefit checks accordingly from proper reserve categories.

· Determines amounts owed to all parties for settlements and issues settlement checks accordingly from proper reserve categories.

· Reviews compensation orders to ensure compliace with the Workers Compensation Regulations.

· Calculates coordination of benefits, (i.e. pensions, SSI, age reduction, unemployment and COLA).

· Analyzes claim system data to determine the input needed into our EDI vendor system.

· Files required initial and subsequent jurisdictional filings via EDI, paper, and State Websites.

· Researches and resolves errors received from jurisdictional filings

· Stops and voids payment checks as requested for all jurisdictions.

· Validates, investigates and completes refund and transfer documents for all jurisdictions.

· Analyzes, validates, approves and processes attorney, legal, IME, vocational rehabilitation, medical management and all other vendor invoices for all jurisdictions.

· Issues penalty checks and files appropriate jurisdictional filings for penalties.

· Prepares form letters and composes general correspondence.

· Alerts Claim Handlers on reserve deficiencies.

· Participates on projects as requested.

· Keeps apprised of changing rules for data submission from regulatory agencies.

· Posts internal claim costs where applicable.

· Posts manual payments.

Additional Responsibilities of Claims Payment and Compliance Specialist II:

· Performs all duties of Claims Payment and Compliance Specialist I. In addition, is responsible for complex indemnity related work and processes.

· Assists as a subject matter expert with the creation of training, procedural and workflow documentation.

· Provides training and mentoring to Claims Payment and Compliance Specialist I.

· Works with minimal supervision.

This description identifies the responsibilities typically associated with the performance of the job. The percentage of time in any responsibility may vary between positions. Other relevant essential functions may be required.

EMPLOYMENT QUALIFICATIONS:

EDUCATION REQUIRED: 

High School Diploma or G.E.D. Advanced training or college level coursework in business, accounting, or insurance. Combination of education and experience may be considered in lieu of additional training or coursework.

Additional Education for Claims Payment and Compliance Specialist II:

Minimum of Associates Degree in business or a related field. Additional training, work experience, or course work in workers compensation, insurance or accounting. A combination of education and experience may be considered in lieu of formal education.

EXPERIENCE REQUIRED: 

Claims Payment and Compliance Specialist I:

Two years experience in an insurance or finance organization performing similar duties or other equivalent relevant experience which provides the necessary skills, knowledge and abilities.

Claims Payment and Compliance Specialist II:

Three years experience in an insurance or finance organization with demonstrated technical knowledge in Workers’ Compensation, or other equivalent relevant experience which provides the necessary skills, knowledge and abilities, including one year of experience as a Claims Payment and Compliance Specialist I.

SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED: 

Claims Payment and Compliance Specialist I:

· Knowledge of computers.

· Basic knowledge of spreadsheet software with data entry ability.

· Basic knowledge of Word Processing software.

· Excellent organizational skills and ability to prioritize work to meet established deadlines.

· Math skills with the ability to use a ten-key calculator.

· Demonstrated ability to proofread correspondence for accuracy of spelling, grammar, punctuation and format.

· Excellent verbal and written communication skills.

· Demonstrated ability to manage work with minimal direction.

· Demonstrated ability to be an independent thinker to solve issues.

· Ability to enter alpha-numeric data accurately.

· Ability to verify data for accuracy.

· Basic knowledge of CPT, ICD9/ICD10 and drug codes.

· Basic knowledge of the Workers Compensation Act for states handling.

· Basic knowledge of Claims process.

· Basic knowledge of medical terminology.

· Basic knowledge of legal terminology.

· Ability to use reference resources and apply information accordingly.

Claims Payment and Compliance Specialist II:

· Knowledge of computers.

· Knowledge of spreadsheet software with data entry ability.

· Basic knowledge of Word Processing software.

· Excellent organizational skills and ability to prioritize work to meet established deadlines.

· Math skills with the ability to use a ten-key calculator.

· Demonstrated ability to proofread correspondence for accuracy of spelling, grammar, punctuation and format.

· Excellent verbal and written communication skills.

· Demonstrated ability to manage work with minimal direction.

· Demonstrated ability to be an independent thinker to solve issues.

· Ability to enter alpha-numeric data accurately.

· Ability to verify data for accuracy.

· Demonstrated knowledge of the Workers Compensation Act for states handling.

· Demonstrated knowledge of Claims process.

· Demonstrated knowledge of medical terminology.

· Demonstrated knowledge of legal terminology.

· Demonstrated knowledge of CPT, ICD9/ICD10 and drug codes.

· Ability to use reference resources and apply information accordingly.

ADDITIONAL EDUCATION, EXPERIENCE, SKILLS, KNOWLEDGE AND/OR ABILITIES PREFERRED: 

· Additional training, work experience, or course work in workers compensation, insurance or accounting.

· Insurance Institute of America Certification (IIA certification).

· Workers’ Compensation Experience – CPCS1

WORKING CONDITIONS:

Work is performed in an office setting with no unusual hazards.

REQUIRED TESTING: 

Claims Payment and Compliance Specialist I: Basic Windows, Basic Excel, Basic Word, Reading Comprehension, Alpha Numeric, 10-Key, Math, Proofreading.

Claims Payment and Compliance Specialist II: Basic Windows, Intermediate Excel, Basic Word, Reading Comprehension, 10-Key, Math, Proofreading.