ForMotion Clinic · 4 weeks ago
Workers Compensation Specialist
United States
Full-time
Remote
Entry, Mid Level
2+ years expForMotion Clinic is a global network of Orthotic and Prosthetic Patient Care clinics focused on providing compassionate care for patients with mobility challenges. The Workers’ Compensation Specialist will manage the authorization and reimbursement strategy for workers’ compensation claims, ensuring compliance and effective communication between clinics and payers.
Hospital & Health Care
Responsibilities
Expedite the intake of incoming referrals, ensuring immediate coordination of initial evaluations to maintain clinical momentum and prevent care delays
Oversee and verify accurate patient and payer profiles within the EMR, ensuring all state-specific jurisdictional guidelines, benefit limitations, and coverage scopes are identified at the point of entry
Proactively request and review clinical documentation from referring providers to ensure all necessary records for authorization are present and compliant
Oversee and handle the process of Preparing, submitting, and aggressively follow-up on Prior Authorization (PA) requests. Ensure all approvals are secured and documented before casting, fabrication, or fitting begins
Exercises independent discretion to categorize and prioritize the caseload, determining which high-risk or high-value claims require immediate escalation or specialized advocacy
Track authorization lifecycles and expiration dates, submitting renewal requests preemptively to ensure an uninterrupted patient care plan
Determines carrier network and ultimate responsible payer to ensure appropriate reimbursement
Partner with carriers and Third-Party Administrators (TPAs) to secure Purchase Orders (POs), Single Case Agreements (SCAs), or Letters of Authorization (LOAs) prior to delivery
Holds the authority to negotiate Purchase Orders (POs), Single Case Agreements (SCAs), and Letters of Authorization (LOAs), and decides when payer terms are financially acceptable or when to escalate for further negotiation based on margin requirements
Independently prices fee schedule exceptions and NOC (Not Otherwise Classified) codes, ensuring that complex O&P devices are reimbursed at rates that sustain organizational profitability
Maintain meticulous records of authorized HCPCS codes and approved rates to ensure seamless hand-offs to the billing department and 100% reimbursement accuracy
Functions as the subject matter expert for clinical teams regarding federal and state-specific workers’ compensation laws, providing the necessary regulatory insights to ensure that clinical care plans align with jurisdictional reimbursement requirements and coverage mandates
Review clinical coding and documentation to ensure strict compliance with federal and state workers’ compensation laws and specific jurisdictional mandates throughout the pre-delivery phase
Serve as the primary liaison between clinicians, adjusters, TPAs, and UR nurses to facilitate seamless authorization and communication standards
Process and monitor workers’ compensation claims from initial referral through final delivery (hand-off to billing)
Work closely with other internal departments including clinic staff, contracting, and revenue cycle departments to ensure timely care, accurate reimbursement, and clean claim submission
Provide regular feedback on authorization workflows, highlighting denial trends and negotiation bottlenecks to ensure timely payer approvals
Perform additional duties assigned to support the evolving operational needs and financial success of ForMotion Clinics
Qualification
Required
Bachelor's degree in business, healthcare, or related field or equivalent combination of education and experience required
2+ years of experience in the O&P industry utilizing EMR systems
Prior experience and working knowledge of WC carriers, third-party administrators, and WC including authorizations, pricing/negotiations, and appeals/denials
Strong comprehension of State and Federal WC regulations and interpretation of payer contract language
Proficient with Microsoft Office, Opie/Nymbl EMRs, ICD10 coding, medical terminology
Preferred
Prior experience as a Patient Care Specialist or other administrator within the company's shared services departments desired, but not required
Benefits
Competitive Compensation Packages
Medical, Dental, and Vision Benefits
401(k) Retirement Plan with employer matching contribution
8 paid holidays
13 vacation days, birthday and two (2) volunteer day
8 sick days within your first year of employment
Paid Parental Bonding
Company
ForMotion Clinic
ForMotion is a network of over 150 Orthotic & Prosthetic patient care clinics in more than a dozen countries.
1001-5000 employees
Funding
Current Stage
Late StageCompany data provided by crunchbase