Claims Customer Service Representative - CA

SUMMARY: 

Primarily responsible for the customer service process associated with workers compensation claims which includes servicing customers who contact us via the ACD phone line and supporting the claims management process for all claims teams across the Enterprise. Provides primary support for California jurisdictional claims. Acts as a back up to the claims intake process. Acts as a backup to the Service Center Business Development and Provider Relations teams on the ACD phone line. Please note that this position has an end shift time of 6:00 pm. 

 

· Inputs notes into medical bill review web-based system for disputes/denials.

· Manually produces claim welcome packets as requested.

· Researches outstanding checks for escheatment process and mails form letter to check recipient if applicable.

· Forwards travel documents back to sender requesting additional information.

PRIMARY RESPONSIBILITIES: (Brief bullet points detailing the major duties, not tasks, for this job and the % of time spent on each. Please list them in the order of importance).

· Supports the customer service work and processes for the Enterprise claims teams as well as the Subrogation Teams.

· Answers claim inquiries from policyholders, agents, injured workers, attorneys, pharmacies, medical providers for multiple jurisdictions for the Enterprise claims teams. Provides verification of claim status for multiple jurisdictions using multiple technology sources.

· Performs all facets of IME’s, AME’s, DDE’s, QME’s and any other independent type evaluation needed for the claim file.

· Provides backup as needed to Claims Document Analysts to review and analyze incoming documents and assign the appropriate document sub type to them.

· Reviews each document and adds pertinent information to the document keywords and to appropriate data fields in the claim system.

· Re-indexes and appropriately routes documents that have been assigned an improper document type or have been attached to an incorrect claim.

· Downloads electronic medical records from various vendors.

· Assists with the resolution of FROI errors.

· Adds legal matters and pertinent litigation information to the claim system upon receipt of legal documents.

· Reviews, researches, and properly routes all unidentified claims mail for all brands within the Enterprise.

· Provides backup to the Claims Processing Associates for review, research, and proper routing of priority unidentified claims mail for all brands within the Enterprise.

· Processes Claims Subpoenas. Performs all facets of the following referrals: Utilization review, Medical Management, Vocational Rehabilitation, Litigation, and all other Vendor Referrals as requested.

· Participates in projects to improve processing and workflow.

· Provides PPO, MPN, HCN provider names and/or general program information to customers

· Updates claim system with vital information changes.

· Updates document management system when claim number changes occur.

· Provides backup to intake for multi-state claims processing.

· Produces forms, memos, reports, information and letters as requested.

· Provides policyholders, agents, and others as requested with copies of first report of injuries.

· Corrects department and location information on loss runs as requested.

· Inputs data into legal billing system.

· Types, photocopies, faxes as necessary.

· Organizes file materials in date order to be provided to various attorneys and vendors either via the vendor portal or another delivery method.

· Assigns services requests to TPA and other vendors via the vendor portal.

· Communicates with appropriate state WC division to discuss various issues.

· Makes contact with employer and/or injured worker if necessary to obtain information.

· May participate with training of team members.

· Serves as a resource with creation of documentation of general and state specific procedures as it relates to this position.

· Communicates and collaborates with team members to ensure the appropriate and timely handling of claims.

· Performs all tasks specified for multiple jurisdictions for all Enterprise Claims Teams.

 

Additional duties for California claims include but are not limited to:

· RFA processing on claims.

· IMR/IBR processing on claims.

· AME/QME processing on claims.

· Re-index claims on ISO website.

· File and Serve appropriate documents to Primary Treating Physician on claims.

· Generate Lien Objection Letters on claims.

· Request medical records on claims via Vendor.

· Generate and mail Enzyme letters to Injured Workers and Treating Physicians on claims.

· Create Special Handling Forms with all appli