Claims Processing Associate

SUMMARY:

This role will focus on maintenance of our incoming workload, issue resolution and first report of injury (FROI) issues.  This position determines jurisdiction for entry of first notice of injury (FNOI) from multiple sources and distributes to the proper destination. Enters and supports priority and special requests, including correcting newly-created claims. 

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

• Identifies jurisdiction, date of injury and special/additional handling items; researches and re-indexes non-new claim submissions to route to appropriate handling. 
• Receives incoming general new claims calls for all entities; backup for ACD calls in the event of telephone system shutdown.
• Makes changes, corrections and updates on newly created and/or existing claims or submissions as well as guiding end-users on process techniques in various applications.
• May serve as a resource regarding intake-related issues, i.e., determine jurisdiction, assist in clearing policy issues to process claim; in finding coverage or other information.
• May participate in training employees new to the role.
• Processes Workers’ Compensation claims retrieved from Open Pool queues or via telephone; codes body part, diagnosis and cause of injury by entering submitted data in the claims system reviews claim for accuracy prior to completion and performs all tasks specified for state-specific requirements after claim setup. 
• Confirms policy coverage for date of injury, business location and injury location; requests policy update for locations as needed. 
• Maintains department procedures, working instructions and job aides; may participate in creating new workflows or workflow changes.

• Researches multiple state and internal systems and documents and routes/or indexes incoming mail to appropriate region and/or department from unidentified mail queue.

• Forwards unidentified mail to sender using appropriate form letters.

• Routes documents to medical bill review vendor.

• Work may be performed at varied hours/days/shifts.

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.

EDUCATION AND EXPERIENCE 

Relevant combination of education and experience may be considered in lieu of degree.

1. EDUCATION REQUIRED: (Brief paragraph detailing the minimum education required, including certifications) Do not state preferred qualifications.

High school diploma or G.E.D.

1. EXPERIENCE REQUIRED: (Minimum experience required to perform this job) Do not state preferred experience.

Minimum of two years of general office experience, including customer service experience that provides the required skills, knowledge and abilities. 

QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

OTHER SKILLS AND ABILITIES 

1. Excellent verbal and written communication skills.

• Ability to be an independent thinker to solve issues.

• Excellent organizational skills and ability to prioritize work to meet established deadlines.

• Basic knowledge of computers and spreadsheet software with data entry ability Basic knowledge of word processing software.

• Excellent customer service skills

• Knowledge of multi-functional telephone system.

• Ability to proofread correspondence for accuracy of spelling, grammar, punctuation and format.

• Ability to verify data for accuracy.

• Ability to multi-task i.e. interacts on telephone while entering data.

• Ability to work effectively with various business units. 

• Ability to train and coach others to perform the core responsibilities. 

1. Ability to work varied hours/days/shifts.

1. ADDITIONAL EDUCATION, EXPERIENCE, SKILLS, KNOWLEDGE AND/OR ABILITIES PREFERRED: (Briefly detail the preferred education, experience, skills, knowledge and/or abilities desired to perform this job, including certifications). These are in addition to the required qualifications - Do not state required qualifications.
2. Insurance Institute of America (IIA) or other insurance related coursework.
3. Knowledge of Workers Compensation or insurance.
4. Basic knowledge of spreadsheet software.
5. Knowledge of medical terminology.
6. Knowledge of claims reporting process for multiple states.
7. Experience using a document management system with workflows.
8. Other insurance related coursework.
9. Experience providing customer service over the phone.
10. Excellent telephone etiquette.

ADDITIONAL INFORMATION

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. This job description does not constitute a contract for employment.

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