Workers' Compensation Claims Technician

Provides injured workers and customers with accurate, timely information and quality service. Conduct investigation to secure essential facts from injured worker, employer and providers regarding workers' compensations through telephone or written reports. Verifies information from claimants, physicians, and medical providers to assess compensability and/or causal relation of medical treatment, and make evaluations for cases with claim specific on-going medical management. Provides on-going medical case management for assigned claims. Initiates calls to injured worker and medical provider if projected disability exceeds maximum triage model projection or to resolve medical treatment issues as needed. Maintains contact with injured worker, provider and employer to ensure understanding of protocols and claims processing and medical treatment. Continually assesses claim status to determine if problem cases or those exceeding protocols should be referred to Claims Service Team and/or would benefit from, MP RN review or other medical /claims resources. Arranges Independent Medical Exam and Peer Review as necessary. Maintains accurate records and handles administrative responsibilities associated with processing and payment of claims. Records and updates status notes; documents results of contacts, relevant medical reports, and duration information per file posting standards including making appropriate medical information viewable to customers in Electronic Document Management (EDM). Generates form letters following set guidelines (i.e., letters to physicians projecting disability, letters confirming medical treatment and disability and letters outlining expected outcome to employers). Authorizes payment of medical payments and/or medical treatment. Recognizes potential subrogation cases, prepares cases for subrogation and refers these cases to the Subrogation Units. High school diploma plus 1-3 years' of related customer service experience or applicable insurance knowledge. Licensing required in some states. Effective analytical skills required to learn and apply basic policy/contract coverage and recognize questionable coverage/contract situations (which necessitate supervisory involvement) along with effective interpersonal skills to explain the facts and logic used to arrive at decisions in a way that the customer understands. Effective written skills to compose clear, succinct descriptions when posting files and drafting correspondence. Good telephone and typing skills required. Ability to learn when to make proper use of medical management resources, know when to use them and follow through with medical management information received.