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Insurance Claims

Conducts a 1 to 3-point contact on the managed claims, which is dependent on either the facts of the case or the claim type; determines compensability of claims, manages the medical treatment program, and assists in the return-to-work process. If, in the normal course of my duties and responsibilities, I am required to access protected health information (PHI) and electronic protected health information (EPHI) for the purposes of treatment, payment and operations within Northeast Georgia Health System, I will limit such access to only the minimum necessary amount of PHI and EPHI necessary to perform the functions of my job.

KBSkills

ACTIVE

Job Category:Human ResourcesWork Shift/Schedule:8 Hr Morning - AfternoonNortheast Georgia Health System is rooted in a foundation of improving the health of our communities. About the Role: Job Summary Primarily responsible for the investigation and management of workers’ compensation claims. Conducts a 1 to 3-point contact on the managed claims, which is dependent on either the facts of the case or the claim type; determines compensability of claims, manages the medical treatment program, and assists in the return-to-work process. This includes calling and discussing potential claim activity and work-related injuries claimants and providers.  Ensures best outcomes for employees in terms of a safe workplace, supervises care plans, and manages restricted duty for injured workers. Collaborates with employees, supervisors, care providers, claims processors, brokers, nurse case managers, and attorneys to properly manage work-related injuries.  Minimum Job Qualifications <ul><li>Licensure or other certifications: Claims Adjuster Licensure (Licensure is to be obtained within 6 months of hire).</li><li>Educational Requirements: Associates Degree. In lieu of a degree, five (5) or more years of relevant experience is acceptable </li><li>Minimum Experience: Five (5) or more years experience in Occupational Health, Worker's Compensation, or other claims administration.</li><li>Other:</li></ul> Preferred Job Qualifications <ul><li>Preferred Licensure or other certifications:</li><li>Preferred Educational Requirements: </li><li>Preferred Experience:</li><li>Other:</li></ul> NGHS Core Competencies 1. I Show Vulnerability when I:<ul><li>trust others and assume positive intent.</li><li>am emotionally accessible and transparent without hidden agendas.</li><li>acknowledge weaknesses and accept responsibility for mistakes.</li><li>am comfortable saying “I don’t know” and asking for help.</li><li>seek and accept feedback in a non-defensive manner.</li><li>forgive others and give the benefit of the doubt.</li></ul>2. I Display Empathy when I:<ul><li>seek to know others on a deeper level.</li><li>work to ensure others feel included.</li><li>accept others for who they are without judgment.</li><li>show concern for the well-being and challenges of others.</li><li>consider the human impact before making decisions.</li></ul>3. I Demonstrate Courage when I:<ul><li>do not hold back on anything that needs to be said.</li><li>do the right thing even when that is difficult.</li><li>speak my own truth, even when that means standing alone.</li><li>address potential conflict quickly and directly.</li><li>commit to seeing a difficult conversation through to the end.</li></ul>4. I Demonstrate Radical Listening when I: <ul><li>seek to understand the other person’s viewpoint first, before expressing my own viewpoint.</li><li>listen for the unsaid.</li><li>ask questions to confirm understanding. </li><li>accept others’ perceptions as their truth.</li><li>take action to help others feel fully heard and seen.</li><li>pursue as many different viewpoints as possible and embrace the bearer of bad news.</li></ul>5. I Promote Teamwork when I:<ul><li>treat others in a respectful manner, regardless of their position, identity, and background.</li><li>encourage and support my coworkers.</li><li>value and acknowledge others for their contributions to the success of the team and NGHS. </li><li>put the good of the team and NGHS first.</li><li>strive to find common ground to solve problems for the good of NGHS.</li><li>cut across boundaries to get things done.</li></ul>6. I Hold Others Accountable when I:<ul><li>provide clear, consistent, and frequent communication about what is most important.</li><li>clarify what is less important to establish clear priorities.</li><li>help others see their blind spots.</li><li>look for every opportunity to provide reinforcing feedback.</li><li>provide immediate and actionable corrective feedback.</li></ul>7. I Strive for Continuous Improvement when I:<ul><li>hold myself personally responsible to seek improvements every day.</li><li>experiment regularly with new ideas and approaches.</li><li>demonstrate initiative and perseverance to overcome obstacles and resistance to change.</li><li>embrace mistakes and pivot quickly if a new approach fails.</li><li>seek to always be better tomorrow than today.</li></ul> Organization Expectations <ul><li>Quest: Demonstrates/utilizes Quest tools in department.</li><li>Talent Development:  Coaches and develops staff.</li><li>Safety:  Promotes patient, visitor and staff safety and effectively manages hazards that lead to injury or harm.</li><li>Productivity:  Meets productivity expectations.</li><li>Regulatory Compliance:  Ensures department’s compliance with all regulatory, DNV, mandatory education, and similar requirements.</li></ul> Key Performance Indicators (KPI) Identifies unit/department level goals that align with the organization's Key Performance Indicators. HIPAA (Health Insurance Portability and Accountability Act) If, in the normal course of my duties and responsibilities, I am required to access protected health information (PHI) and electronic protected health information (EPHI) for the purposes of treatment, payment and operations within Northeast Georgia Health System, I will limit such access to only the minimum necessary amount of PHI and EPHI necessary to perform the functions of my job.  If access is not required in the normal course of my duties and responsibilities, I will not access PHI or EPHI.   Job Specific and Unique Knowledge, Skills and Abilities <ul><li>Knowledge of insurance principles and claims administration</li><li>Knowledge of Georgia Worker's Compensation regulations; ability to understand, interpret, and apply complex regulations to claims</li><li>Knowledge of medical, insurance, and related legal terminology; ability to organize, analyze and interpret technical information</li><li>Skill in examining documents for completeness, accuracy and compliance with specific requirements</li><li>Ability to responsibly handle and maintain confidential information</li><li>Ability to maintain effective working relationships with supervisors, injured workers, providers of care, and vendors</li><li>Ability to prioritize work and perform duties with accuracy and attention to detail </li></ul> Essential Tasks and Responsibilities <ul><li>Determines the validity and compensability of claims.</li><li>Contacting employee/injured worker to obtain information related to their claim. Ability to take accurate documentation.</li><li>Advises claimants of their rights and responsibilities while receiving medical care and provides assistance with the compensation process.</li><li>Maintains detailed record for each claimant.</li><li>Coordinates light/limited duty work assignments. Facilities the return to work process for all employees.</li><li>Works with the third party administrator to ensure appropriate and timely claim information is set-up.</li><li>Monitors medical costs associated with work related medical care including coordinating billing for work comp services for medical, equipment, and pharmacy changes. Reviews all medical bills to determine payment is accurate. </li><li>Manages the on-going medical treatment program. Assist in creating Panel of Providers annually. </li><li>Maintains up to date OSHA log at all times.</li><li>Participates actively in quarterly claims reviews with attorney and claims adjuster.</li><li>Actively participates in identifying trends, advising on remediation, and works with Employee Health Manager and department leaders on improvement ideas.</li></ul> Physical Demands <ul><li>Weight Lifted: Up to 20 lbs, Occasionally, 0-30% of time</li><li>Weight Carried: Up to 20 lbs, Occasionally, 0-30% of time</li><li>Vision: Moderate, Frequently 31-65% of time</li><li>Kneeling/Stooping/Bending: Occasionally 0-30%</li><li>Standing/Walking: Occasionally 0-30%</li><li>Pushing/Pulling: Occasionally 0-30%</li><li>Intensity of Work: Occasionally 0-30%</li><li>Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding</li></ul>Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals.  NGHS: Opportunities start here.Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.

Northeast Georgia Health System, Inc

Specialist-Claims Certified

Analysis Skills

Billing

Brokerage

Certified Case Manager (CCM)

Claims Management

Claims Processing

Coaching

Detail Oriented

Establish Priorities

HIPAA (Health Insurance Portability and Accountability Act)

Health Insurance

Health Plan

Information/Data Security (InfoSec)

Legal

Lift/Move 20 Pounds

Medical Billing

Medical Equipment

Medical Treatment

OSHA

Occupational Health

Patient Care

Patient Safety

People Management

Performance Metrics

Pharmacy

Physical Demands

Regulations

Returns Processing

Safety/Work Safety

Talent Management

Time Management

Trend Analysis

Worker's Compensation

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