Job Summary: The Claim Review Specialist is responsible for the intake, review, and processing of workers' compensation claims while providing exceptional customer service to employers, injured workers, and medical providers. This role gathers and verifies claim information, obtains medical documentation, maintains accurate records, and ensures timely claim submission and updates within company systems and regulatory requirements. The specialist proactively manages claims, supports early return-to-work initiatives, conducts follow-up communications, and collaborates with team members to facilitate effective claim resolution.
Principal Duties & Responsibilities:
- Reports directly to the Claim Review Specialist Team Leader
- Enter and process initial claims in UniSource, complete initial and/or follow-up calls to employer, provider, IW, and BWC as appropriate while documenting the results of gathered information. Additionally, responsible for complete follow-up on claims, resulting in transition to the Return to Work Specialist or case closure as appropriate, including gathering any additional information on RTW, missing claims master fields, continued treatment, etc.
- Gather complete information on all mandatory UniSource system field requirements to ensure accurate transmission to the BWC
- Gather all initial and subsequent medical documentation necessary to process potential claim updates
- Assist in identifying RAW and Onsite Therapy candidates where appropriate
- Proactive claims management, early RTW intervention, and transfer of claims to Return to Work Specialist for continued RTW management when appropriate
- Assists other Claim Review Specialists on the team
- Answering incoming and making outgoing phone calls
- Provide excellent customer service to all internal and external customers
- Required to meet team quality and productivity standards
- Maintain and develop teamwork within all departments of UniComp
- Other duties as assigned by Management
- Maintain and exhibit Sheakley Core Values
Qualifications:
- Knowledge and skills at a level normally acquired through the completion of High School education or equivalent
- Typing 50-60 WPM
- Ability to handle sensitive information and maintain a high level of confidentiality
- Proficiency in Microsoft Office products including Word, Excel, Outlook, etc.
- Medical Terminology or equivalent experience
- Previous customer service experience preferred
Requirements:
- Attention to detail, flexibility, and strong ability to multi-task
- Problem solving ability
Physical and Mental Demands:
- Ability to sit for prolonged period of time
- Ability to answer high call volume while maintaining accurate system notes
This job description is not intended to be all inclusive and the employee will also perform other reasonably related business duties as assigned by the immediate supervisor and other management as required.