Intern - Risk Management - Full Time - Days

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

1. Bill Review Responsibilities
   1. Reviews provider fee bills and adjusts bills to the appropriate rate per state guidelines; Prepares appropriate notice to providers as mandated by state requirement
   2. Maintains and stays current with statutory changes of bill repricing regulations
   3. Calculates and establishes the appropriate wage calculations per state guidelines
   4. Determines appropriate benefit adjustments as required per state guidelines
   5. Researches state rules and regulations to maximize bill reduction according to state guidelines and regulations
   6. Reviews medical records to ensure that procedures have been billed correctly or if the bills can be down coded and make appropriate adjustments
   7. Corresponds with the providers regarding adjustments or down coding and monitors for response with statemandated timeframe before the discount can be applied
   8. Updates procedures when new State regulations are issued
   9. Reviews and monitors weekly Audit Reports for timely payment of outsourced fee bills
   10. Reviews investigates and addresses errors on quarterly bill review audits
   11. Researches status and follows up regarding unclaimed funds
   12. Posts credits to the claims
   13. Reviews workers compensation claims and bill status. Conferences with providers on payment status and the status of bills
2. Claims Assisting/Management Responsibilities
   1. Maintains litigation log and ensures all hearings are attended by the assigned representative; Prepares claim file for referral to a hearing representative for litigation
   2. Prepares claim file for appropriate referral for medical case management
   3. Schedules independent medical examination and prepares claim file for such examination
   4. Obtains and secures documentation necessary for the management of the claim
   5. Assists with Index Report as needed. Requests prior claim information from the insurance carrier and enters notes into the Riskmaster system
   6. Schedules medical appointments and diagnostic testing within state timeframe. Sends appropriate letters to all parties notifying them of appointment dates
3. Assists Claims Administrators with new claims on gathering medical information and/or sending claims status letters
4. Copies files for hearings Independent Medical Evaluations and medical appointments
5. Reviews and checks established weekly compensation and enter into Riskmaster system I 0. Assist Claims Administrators with various administrative functions as requested
6. Management of a TPA caseload which includes the following duties:
   1. Contact with the business unit employee and physician upon receipt of a new claim
   2. Prepares and forwards all new claims to the TPA
   3. Investigates any preexisting conditions prior claims and the validity of a new claim
   4. Monitors treatment and work status through continuous communication with the business unit TPA and physician
   5. Monitors litigation status through continuous communication with the TPA and defense counsel
   6. t) Evaluates files and make settlement recommendations. Coordinates the process to effect a final settlement
   7. Ensures all claims are properly reserved and provides the appropriate authority promptly
   8. Maintains diaries phone calls and incoming mail on their caseload
   9. Evaluates and monitors for appropriateness of authorized medical treatment by TPA
   10. Ensures TPA is properly handling the claim
   11. Coordinates effective return to work
   12. Prepares and coordinates TPA Claim Audits
   13. Liaison between business unit injured worker provider. and TPA to coordinate work/treatment activity
7. 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

PREFERRED QUALIFICATIONS

Education:

Skills:

Years of Experience:

License:

Certification:

WORKING CONDITIONS

Personal Protective Equipment:

Physical Demands: Primarily sedimentary position.

The above list of accountabilities is intended to describe the general nature and level of work performed by the incumbent; it should not be considered exhaustive.

ProMedica is a missionbased notforprofit integrated healthcare organizational headquartered in Toledo Ohio. For more information please visit applicants will receive consideration for employmentwithout regard to race color national origin ancestry religionsex/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

Equal Opportunity Employer/DrugFree Workplace