In accordance with State and Federal workers compensation laws and regulations, creates and maintains medical claim information and industrial medical reports using internal applications and systems. Determines correct employer, insurance carrier and claim number for assignment to claim file and reports. Obtain all necessary information for the completion of reports.
Ensures correct assignment of industrial visits for billing and reporting. Investigates potential reportable industrial treatment and prepares claim files and reports accordingly. Communicate with employers, insurance carriers and other permissible parties.
Ensure follow up treatment is scheduled in accordance with the treatment plan. Essential
Create and Maintain Reports: For all medical services related to treatment of industrial injuries or illnesses: Create and maintain complete industrial claim files using internal systems. Obtain, validate and update all necessary patient, employer and carrier information needed to create, complete and/or maintain industrial medical reports as required by law using internal applications or systems. Using daily registration reports, internal systems or other means, track necessity of industrial documentation and create reports linked to industrial claim file.
From physicians notes, abstract information necessary to prepare industrial medical reports. Enter data into the internal applications and systems. Ensure appropriate diagnostic codes.
Obtain necessary signatures from providers as appropriate. Preform quality assurance control by linking registrations and documentation to correct industrial claims file. Ensure follow up treatment is scheduled in accordance with the treatment plan.
Transmit required information, reports and forms to appropriate insurance claims administrator in a timely manner and within program service standards and/or applicable state or federal law. Prepare other related industrial injury forms as required by applicable state or federal law. Late Discoveries and Out of Occ: Investigate and validate late discoveries and services rendered outside of the Occupational Health Department.
Create reports and claim files for late discovery cases using internal systems and applications. Notify Revenue Cycle upon discovery of billable services incorrectly registered as non-industrial. Investigate notifications of previously unidentified industrial cases from insurance claims administrators, Revenue Cycle, employers, patients and others.
Review patient medical records for services related to the alleged industrial injury and generate required reports. Work cooperatively with Revenue Cycle to obtain information needed to complete reports and release bills. Document and create claim using internal applications and systems to support billing for industrial pharmacy charges not associated with existing claims (Meds Only).
Process Claims: Process and document incoming and outgoing correspondence related to the claim. Review, document and process incoming mail/correspondence and inquiries related to industrial cases. Notify Revenue Cycle and other necessary personnel of denied and unauthorized claims.
Process and document administrative closures. Contact employers, claims administrators and others to obtain treatment authorization and to identify responsible third-party payer, for Workers Compensation visits. Communication: Manage incoming and outgoing phone calls, document and process information from patients, physicians, employers, insurance carriers and other permissible parties.
Other: Support efforts to maintain Regional Service Standards with respect to report timeliness, quality, work status communication, customer inquiries, etc . Actively participates in training new personnel. Actively participates in employer provided training.
Perform other related duties as assigned. Grade 06 Qualifications
Experience Minimum (2) two years experience in Occupational Health OR Workers Compensation, OR Insurance experience in the field of claims processing, adjudication, and claims examiner. Education High School Diploma or General Education Diploma (GED) required. License, Certification, Registration N/A Additional
Must pass medical terminology, Microsoft Word, and Microsoft Excel per testing. Experience with electronic medical records/PC applications. Good verbal/written communication skills.
Must be customer oriented Must be able to work in a Labor/Management Partnership environment. Must be able to pass 40 wpm typing test.
Knowledge of California workers compensation law or claims process. Familiarity with ICD diagnosis coding system. Scheduled Weekly Hours: 40
Day Workdays: Mon, Tue, Wed, Thu, Fri Working Hours Start: 09:00 AM Working Hours End: 05:30 PM Job
Full-time Job Type: Standard Employee Status: Regular Worker Location: Onsite Employee Group/Union Affiliation: A01|SEIU|United Healthcare Workers West Job Level: Entry Level Department: Fresno Orchard Plaza MOB - Occup Med-Industrial Reporter - 0206
$39.12 - $41.16 / hour Travel: No