Senior Claims Payment Specialist
AF Group

SUMMARY:

Primarily responsible for all of the following duties Enterprise wide: Analysis and entry of detailed wage data into the claim system for all states, contact with employers to obtain missing wage information or to clarify information submitted for all states, determination of compensation rate for manual states, issuance of non-indemnity and non-medical payments and manual payments, processing of refunds and transfers, handling route back checks for distribution, audit of payments, posting internal claims costs and excess costs, posting manual payments, research and resolution of returned non-medical checks. Contacts include agents, policyholders, injured workers, attorneys, and other Claims Department staff.

PRIMARY RESPONSIBILITIES:

• Analyze and enter detailed wage information into the claim system.
• Contact policyholder for wage clarification and to obtain necessary information.
• Review payment requests to ensure compliance with the Workers Compensation regulations.
• Files required initial and subsequent. Jurisdictional filings via EDI, paper, and State Websites.
• Researches and resolves errors received from jurisdictional filings.
• Works closely with claim handlers to ensure proper data is being transmitted to State Regulatory Offices.
• Reports to State Regulatory Offices in a timely manner.
• Contacts State Regulatory Offices to discuss/resolve jurisdictional filing issues.
• Reviews penalty notices and works closely with Claims to resolve.
• Maintains accurate records of state reports generated. Reconciles these records against Inputs data into EDI vendor system as needed
• Researches, gathers, compiles and compares reports, memos and other correspondence to ensure state filing compliance for multiple jurisdictions.
• Researches and assists with training in new jurisdictions.
• State benchmark criteria.
• Produces reports for necessary EDI filings that are not system automated.
• Analyzes, Validates, Approves, and Processes Attorney billings, IME, Vocational Rehabilitation, Medical Management and all other vendor invoices.
• Calculates Average Weekly Wage and Compensation Rate for states not programmed into the claim system.
• Alerts Claims Handlers on reserve deficiencies.
• Verifies, calculates, and pays approved injured worker travel and miscellaneous expenses.
• Assists Finance and Claim Handlers with EFT Process as requested.
• Audits wage payments and other payments for accuracy.
• Contacts agents, policyholders, and injured workers to verify or gather claim information.
• Prepares form letters and composes general correspondence.
• Reviews payment requests to ensure compliance with the Workers Compensation regulations.
• Stops and voids payment checks as requested.
• Posts Excess Payments to claim files at the direction of Claims and Finance.
• Sorts and distributes checks as requested.
• Validates, investigates and completes refund and transfer documents.
• Participates on projects as requested.
• Orients/Trains new employees.
• Mentors team members.
• Assists with the creation of procedural and workflow documentation.
• Post internal claim costs.
• Post manual payments.

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. required. Minimum of an Associates degree in insurance or related field, but a combination of education and experience may be considered in lieu of formal education.

EXPERIENCE REQUIRED:

Four years experience in an insurance organization including one year experience as a Claims Payment Specialist II. Demonstrated technical knowledge in Workers Compensation or other equivalent relevant experience, which provides necessary skills, knowledge and abilities.

SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:

• Knowledge of spreadsheet software.
• Basic knowledge of word processing software.
• Basic knowledge of computers.
• Knowledge of legal terminology
• Knowledge of medical terminology
• Accurate input of 40 WPM.
• Demonstrated ability to proofread correspondence for accuracy of spelling, grammar, punctuation and format.
• Demonstrated ability to be an independent thinker to solve issues.
• 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 manage work with minimal direction.
• Excellent verbal and written communication skills.
• Ability to use reference resources and apply information accordingly.
• Ability to define and assist with the creation of new processes and procedures.
• Knowledge of the Workers Compensation regulatory guidelines and Claims process.
• Knowledge of CPT, ICD9/10 and drug codes.

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

• Insurance Institute of America Certification (IIA).
• Experience using a document management system with workflows.

WORKING CONDITIONS:

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

REQUIRED TESTING:

Intermediate Excel, Basic Word, Basic Windows, Reading Comprehension, 10-Key, Math, Typing 40wpm and Proofreading.

This job has expired.