Sheakley ยท 3 days ago
Claims Examiner
United States
Full-time
Remote
Entry Level
2+ years exp
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Responsibilities
Establish a three-point contact between the injured worker, employer and provide to gather information needed to file a claim with the Ohio BWC
Communication and collaboration with injured workers (IW), employers, providers, third party administrators (TPA), attorneys, and the BWC to obtain a safe return to work (RTW) while working within BWC designated guidelines.
Effectively apply the MCO process including completion of appropriate first report of injury documentation, medical management templates, documentation of potential barriers to a successful RTW within the scope of the non-clinical position.
Process all Treatment Requests (C-9s) within 72 hours to provide the IW with the treatment medically necessary and appropriate for the Allowed Conditions. Staff C-9 requests with the Nurse Case Manager, or Medical Director as needed.
Follow up with providers to obtain current treatment plans, results of diagnostics and RTW goals. Obtain modified duty availability from employers and communicate to providers and IWs. Obtain restrictions to a full RTW from provider and communicate to the employer and IW.
Properly refer all cases to the Nurse Case Manager when appropriate as well as utilize the RN for all clinical issues pertaining to the IW's claims. Identify IWs who are potential vocational rehabilitation candidates and complete the referral process.
Adherence to all Health Management Solutions (HMS) policies and URAC standards as well as all Confidentiality policies and guidelines. Ensure that all documentation is current, accurate and complete including remaining current with all diaries. Follow all HMS and BWC guidelines for appropriate medical management of claims and participate in educational and informational seminars as needed.
Completion of team peer-to-peer FROI/CE audits, quarterly.
Other duties as assigned.
Qualification
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Required
High School Diploma/GED
Exceptional written, telephonic, and oral communication (public speaking), leadership, problem-solving, interpersonal, and organizational skills required.
Ability to coordinate and organize multiple priorities.
Excellent knowledge of medical terminology
Experience using Microsoft Office programs, especially Excel, Word, PowerPoint, and Access.
Preferred
2 years of MCO experience
Benefits
Health, dental, vision, and life insurance
Additional insurance options: Critical Illness, Long Term, Short Term Disability, Accidental Death and Dismemberment, Employee Assistance Program, Legal Shield
401(k) savings plan with match after 1 year
Continuous professional training and development
8 Paid Holidays
Paid Vacation and PTO available
A paid day off for your birthday and work anniversary
Employee focused culture with appreciation events all year
Company
Sheakley
Serving employers since 1963, Sheakley provides the perfect blend of practical and innovative Risk Management and Safety solutions that help businesses save time, decrease accidents, increase compliance, and reduce overall costs.
201-500 employees
Funding
Current Stage
Growth StageLeadership Team
T
Thomas Pappas
CFO
Recent News
2024-05-18
Company data provided by crunchbase
