Workers Compensation Specialist

• Receive, review, and take appropriate action on claims related to work related injury claims received from the TPA, Fund, Union, NHS, or Workers’ Compensation Attorney
• Communicate with the employees and/or their Attorney, provide guidance during the appeal process (1st and 2nd level appeal), follow up with letters and phone calls, and document process and steps for each case
• Obtain and distribute accordingly the medical records and document needed to proceed with the case
• Provide directives to the TPA on next steps – pay claims or recover on paid claims according to Worker’s Compensation final Case determination
• Assist employees with continuity of care access-related inquiries during the two levels of the appeal process
• Track and submit necessary reports on workers’ compensation cases to the Fund’s Leadership
• Manage the mail process in a timely manner to ensure patient is not disenfranchised by a missed workers compensation mandated deadline
• Maintain a sense of timeliness in the handling of priority cases and reduction requests such as completing case follow ups within timeline guidelines
• Manage difficult calls and return follow-up calls within 24 hours
• Treat referral of settled cases as priority and refer to the TPA within Fund guidelines (usually 24 hours)
• Comply with Federal/States mandates as applied to Workers’ Compensation Cases
• Exemplifies the Fund’s values in leading and fostering a respectful, trusting, and engaged culture of inclusion and engagement

ESSENTIAL QUALIFICATIONS

• 4 ~ 6 years of related experience within Nevada state workers’ compensation claims cases
• Associate’s degree or equivalent work experience, preferred
• Experience with interpretation of benefit plans, including an understanding of limitations, exclusions, and schedule of benefits
• Working knowledge and experience in medical claims adjudication, preferably in a multi-employer environment
• Understanding of Medicare, Medicaid, ACA, DOL regulations, ERISA and HIPAA
• Intermediate level MS Office and MS Excel skills
• Manage competing deadlines and multiple projects in a fast-paced environment
• Excellent communication skills, with the ability to communicate effectively with vendors, state agencies, participants, union staff, and Fund staff and leadership
• Ability to demonstrate good judgment and have excellent critical thinking and problem-solving skills
• Ability to work independently with minimal supervision in a fast-paced environment

Salary range for this position: Salary $58,300 - $72,900. Actual base salary may vary based upon, but not limited to: relevant experience, qualifications, expertise, certifications, licenses, education or equivalent work experience, time in role, peer and market data, prior performance, business sector, and geographic location.

Work Schedule (may vary to meet business needs): Monday~Friday, 7.5 hours per day (37.5 hours per week) as a hybrid employee, 8 – 4pm (PT).

We reward great work with great benefits, including but not limited to: Medical, Dental, Vision, Paid Time-Off (PTO), Paid Holidays, 401(k), Short- & Long-term Disability, Pension, Life, AD&D, Flexible Spending Accounts (healthcare & dependent care), Commuter Transit, Tuition Assistance, and Employee Assistance Program (EAP).

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