Claims Assistant - Senior Care Workers Compensation - Paramount

Paramount Health Care, a ProMedica Health Plan, offers insurance products across six Midwest states. This Ohio-based company, headquartered in Toledo, has more than 685 employees dedicated to serving their health plan members.  

Paramount offers Medicare Advantage and Marketplace Exchange health plans for individuals and families. Paramount maintains accreditation by the National Committee for Quality Assurance (NCQA) for their HMO and Medicare Advantage products.

In addition, Paramount has a full complement of insurance products for employers of any size, including medical, dental, vision and workers’ compensation, as well as vocational rehabilitation, life-care planning and wellness.

As a part of ProMedica, Paramount is driven by ProMedica’s mission to improve your health and well-being. ProMedica has been nationally recognized for its advocacy programs and efforts to address social determinants of health. Paramount strives to provide an exceptional experience to every member. For more information about Paramount, please visit our website at paramounthealthcare.com.

REPORTING RELATIONSHIPS/SUPERVISORY RESPONSIBILITIES

This position reports to the Lead Workers’ Compensation Examiner and does not have any direct reports.

POSITION SUMMARY

Assists in the management of workers' compensation claims by providing support to the   Claims Administrators; Responsible for bill review, repricing, check processing, data collection, medical referrals, and scheduling of medical appointments; case manage small caseload.

ACCOUNTABILITIES

• Bill Review Responsibilities
  • Reviews provider fee bills and adjusts bills to the appropriate rate per state guidelines; Prepares appropriate notice to providers as mandated by state requirement
  • Maintains and stays current with statutory changes of bill repricing regulations
  • Calculates and establishes the appropriate wage calculations per state guidelines
  • Determines appropriate benefit adjustments as required per state guidelines
  • Research state rules and regulations to maximize bill reduction according to state guidelines and regulations
  • Reviews medical records to ensure that procedures have been billed correctly or if the bills can be down coded and make appropriate adjustments
  • Corresponds with the providers regarding adjustments or down coding and monitors for response with state-mandated timeframe before the discount can be applied
  • Updates procedures when new State regulations are issued
  • Reviews and monitors weekly Audit Reports for timely payment of outsourced fee bills
  • Reviews, investigates, and addresses errors on quarterly bill review audits
  • Research status and follows up regarding unclaimed funds
  • Posts credits to the claims
  • Reviews workers' compensation claims and bill status. Conferences with providers on payment status and the status of bills
• Claims Assisting/Management Responsibilities
  • Maintains litigation log and ensures all hearings are attended by the assigned representative; Prepares claim file for referral to a hearing representative for litigation
  • Prepares claim file for appropriate referral for medical case management
  • Schedules independent medical examination and prepares claim file for such examination
  • Obtains and secures documentation necessary for the management of the claim
  • Assists with Index Report as needed. Requests prior claim information from the insurance carrier and enters notes into the Riskmaster system
  • Schedules medical appointments and diagnostic testing within state timeframe. Sends appropriate letters to all parties notifying them of appointment dates
• Assists Claims Administrators with new claims on gathering medical information and/or sending claims status letters
• Copies files for hearings, Independent Medical Evaluations, and medical appointments
• Reviews and checks established weekly compensation and enter into Riskmaster system I 0. Assist Claims Administrators with various administrative functions as requested
• Management of a TPA caseload which includes the following duties:
  • Contact with the business unit, employee, and physician upon receipt of a new claim
  • Prepares and forwards all new claims to the TPA
  • Investigates any pre-existing conditions, prior claims, and the validity of a new claim
  • Monitors treatment and work status through continuous communication with the business unit, TPA, and physician
  • Monitors litigation status through continuous communication with the TPA and defense counsel
  • t) Evaluates files and make settlement recommendations. Coordinates the process to affect a final settlement
  • Ensures all claims are properly reserved and provides the appropriate authority promptly
  • Maintains diaries, phone calls, and incoming mail on their caseload
  • Evaluates and monitors for appropriateness of authorized medical treatment by TPA
  • Ensures TPA is properly handling the claim
  • Coordinates effective return to work
  • Prepares and coordinates TPA Claim Audits
  • Liaison between business unit, injured worker, provider. and TPA to coordinate work/treatment activity
• Other duties as assigned.

REQUIRED QUALIFICATIONS

Education: High School diploma plus additional specialized business courses

Skills: Knowledge of ICD9 and CPT codes; Strong computer skills including Word, Excel, and data entry required; Good grammar and typing skills

Years of Experience: At least three years in a business environment; One year of extensive Workers' Compensation exposure

License:  N/A

Certification: N/A

WORKING CONDITIONS

Personal Protective Equipment:

Physical Demands: Primarily sedimentary position.

ProMedica is a mission-based, not-for-profit integrated healthcare organizational headquartered in Toledo, Ohio.  For more information, please visit www.promedica.org/about-promedica

Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex/gender (including pregnancy), sexual orientation, gender identity or gender expression, age, physical or mental disability, military or protected veteran status, citizenship, familial or marital status, genetics, or any other legally protected category. In compliance with the Americans with Disabilities Act Amendment Act (ADAAA), if you have a disability and would like to request an accommodation in order to apply for a job with ProMedica, please contact employment@promedica.org

Equal Opportunity Employer/Drug-Free Workplace