Claims Payment Specialist I/II
AF Group

SUMMARY:

Claims Payment Specialist I

Primarily responsible for all of the following duties Enterprise wide; Analysis and entry of detailed wage data into the claim system for up to five states, contact with employers to obtain missing wage information or to clarify information submitted for up to five states, issuance of non-indemnity and non-medical payments and manual payments, processing of refunds and transfers, handling route back checks for distribution. Researches and resolves returned non-medical checks. Contacts include agents, policyholders, claimants, attorneys, and other Claims Department staff.

Claims Payment Specialist II

Primarily responsible for all of the following duties Enterprise wide; Analysis and entry of detailed wage data into the claim system for more than five states, which includes manual states, determination of compensation rate for manual states, contact with employers to obtain missing wage information or to clarify information submitted for more than five states, issuance of non-indemnity and non-medical payments and manual payments, processing of refunds and transfers, handling route back checks for distribution, posting manual payments, processing refunds and transfers, research and resolution of returned non-medical checks. Contacts include agents, policyholders, injured workers, attorneys, and other Claims Department staff.

PRIMARY RESPONSIBILITIES:

• Analyze and enter detailed wage information into the claim system.

• Review payment requests to ensure compliance with the Workers Compensation regulations.

• Contact policyholder for wage clarification and to obtain necessary information.

• Verifies, calculates, and pays approved injured worker travel and miscellaneous expenses.

• Stops and voids payment checks as requested.

• Sorts and distributes checks as requested.

• Validates, investigates and completes refund and transfer documents.

• Analyzes, Validates, Approves and Processes Attorney, Legal, IME, Vocational Rehabilitation, Medical Management and all other vendor invoices.

• Contacts agents, policyholders, and injured workers to verify or gather claim information.

• Prepares form letters and composes general correspondence.

• Alerts Claim Handlers on reserve deficiencies.

• Participates on projects as requested.

Additional responsibilities of Claims Payment Specialist II:

• Prepares form letters and composes general correspondence.

• Assists Finance with EFT Process as requested.

• Calculates Average Weekly Wage and Compensation Rate for states not programmed in the claim system.

• Performs all duties under Claims Payment Specialist I for more than five states.

• Files required initial and subsequent jurisdictional filings via EDI, paper, and State Websites.

• Researches and resolves errors received from jurisdictional filings.

• Works closely with claim handlers to ensure proper data is being transmitted to State Regulatory Offices.

• Reports to State Regulatory Offices in a timely manner.

• Maintains accurate records of State reports generated. Reconciles these records against State benchmark criteria.

This description identifies the responsibilities typically associated with the performance of the job. The percentage of time in any responsibility may vary between positions. Other relevant essential functions may be required.

EMPLOYMENT QUALIFICATIONS:

EDUCATION REQUIRED:

High School Diploma or G.E.D. Advanced training or college level coursework in business, accounting, or insurance. Combination of education and experience may be considered in lieu of additional training or coursework.

EXPERIENCE REQUIRED:

Claims Payment Specialist I

Two years general office experience performing relevant duties that provides the necessary skills, knowledge and abilities.

Claims Payment Specialist II

Two years general office experience and one year as a Claims Payment Specialist I

OR

Three years general office experience including one year in an insurance organization with demonstrated technical knowledge in Workers' Compensation, which provides the necessary skills, knowledge, and abilities.

SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:

Claims Payment Specialist I:

• Basic knowledge of computers and spreadsheet software with data entry ability.

• Basic knowledge of Word Processing software.

• Excellent organizational skills and ability to prioritize work to meet established deadlines.

• Math skills with the ability to use a ten-key calculator.

• Ability to proofread correspondence for accuracy of spelling, grammar, punctuation and format.

• Excellent verbal and written communication skills.

• Demonstrated ability to manage work with minimal direction.

• Demonstrated ability to be an independent thinker to solve issues.

• Ability to enter alpha-numeric data accurately.

• Ability to verify data for accuracy.

Additional Skills/Knowledge/abilities of Claims Payment Specialist II:

• Basic knowledge of CPT, ICD9/ICD10 and drug codes.

• Knowledge of the Workers Compensation Act and Claims process.

• Basic knowledge of medical terminology.

• Knowledge of legal terminology.

• Knowledge of spreadsheet software.

• Ability to use reference resources and apply information accordingly.

ADDITIONAL EDUCATION, EXPERIENCE, SKILLS, KNOWLEDGE AND/OR ABILITIES PREFERRED:

• Additional training, work experience, or course work in workers compensation, insurance or accounting.

• Insurance Institute of America Certification (IIA certification).

• Experience using a document management system with workflows.

• Workers' Compensation Experience.

WORKING CONDITIONS:

Work is performed in an office setting with no unusual hazards.

REQUIRED TESTING:

Claims Payment Specialist I: Basic Windows, Basic Excel, Basic Word, Reading Comprehension, Alpha Numeric, 10-Key, & Math. Proofreading.

Claims Payment Specialist II: Basic Windows, Intermediate Excel, Basic Word, Reading Comprehension, 10-Key, Math, Alpha Numeric, Proofreading