Claims Associate - Workers Compensation
PRIMARY PURPOSE: To analyze reported lower-level workers compensation claims to determine benefits due; and to ensure ongoing adjudication of claims within company standards and industry best practices.
ESSENTIAL FUNCTIONS and RESPONSIBILITIES
- Adjusts medical-only claims and minor lost-time workers compensation claims under close supervision.
- Supports other claims representatives, examiners and leads with larger or more complex claims as necessary.
- Processes workers compensation claims determining compensability and benefits due; monitors reserve accuracy and files necessary documentation with state agency.
- Processes assigned claims and determines benefits due pursuant to the client contract; makes timely claims payments and adjustments.
- Communicates claim action/processing with claimant, client and appropriate medical contact.
- Ensures claim files are properly documented and claims coding is correct.
- May process routine payments and prescriptions and status reports for lifetime medical claims and/or defined period medical claims.
- Maintains professional client relationships.
ADDITIONAL FUNCTIONS and RESPONSIBILITIES
- Performs other duties as assigned.
- Supports the organization's quality program(s).
QUALIFICATIONEducation & Licensing High school diploma or GED required.
Experience One (1) year of general office experience or equivalent combination of education and experience required. Claims industry experience preferred. Licenses as required.
Skills & Knowledge
- Knowledge of Social Security and Medicare application procedure as applicable to line of business
- Excellent oral and written communication skills
- PC literate, including Microsoft Office products
- Analytical and interpretive skills
- Strong organizational skills
- Good interpersonal skills
- Ability to work in a team environment
- Ability to meet or exceed Performance Competencies
WORK ENVIRONMENT When applicable and appropriate, consideration will be given to reasonable accommodations.Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines
Physical: Computer keyboarding, travel as required
Auditory/Visual: Hearing, vision and talking