Workers Compensation Claims Associate

CitiMed; New York (NY); On-site; USD 34,000 - 55,000; Full time

Job summary

CitiMed is seeking a Workers’ Compensation Claims Associate who will independently evaluate and resolve assigned claims in line with statutory guidelines. The role involves coordinating medical care, negotiating settlements, and advocating for clients to ensure cost-effective outcomes.

Ideal candidates have 2–5 years of WC billing experience, strong knowledge of NY regulations, and familiarity with HIPAA compliance.

Qualifications

• 2–5 years of workers’ compensation billing experience.
• Knowledge of NY no-fault and workers’ compensation regulations.
• Familiarity with HIPAA rules and compliance.

Responsibilities

• Independently evaluate, investigate, and resolve assigned workers’ compensation claims.
• Coordinate medical care and negotiate to achieve cost-effective outcomes.
• Serve as an advocate on client claim issues and provide technical expertise.
• Promptly investigate assigned claims from basic to complex medical/indemnity files.
• Make timely compensability determinations per jurisdictional requirements.
• Identify potential fraud indicators and notify management for further investigation.
• Notify excess carriers per guidelines and request timely reimbursement.
• Negotiate settlements within authority and process/track award payments.
• Maintain forms, rules, and regulations relevant to NY WC processes.
• Maintain follow-up systems for all cases to ensure timely reimbursement.
• Ensure a minimum productivity of cases per day and proper documentation.

Skills

WC billing

HIPAA compliance

NY regulations knowledge

Job description

CitiMed is a unique medical facility that provides exclusive healthcare amenities to our community. The range of medical and rehabilitative services offered has been specifically selected to treat traumatic injury patients. We provide a variety of health services including diagnostic and rehabilitation. Our vision directs the evolution of our practice, as we strive to improve our services to the community. All CitiMed offices are multilingual and staffed with individuals to make any experience pleasant. You can learn more about us at https://www.citimedny.com/.

CitiMed is growing rapidly and we are looking for many qualifying individuals to be a part of our team! With the support and hard work of all our employees, CitiMed continues to make its way down a successful road. CitiMed maintains a work culture that allows our team members to feel supported and confident in their work. We offer many learning opportunities with room for professional growth.

Job Description:

The workers' compensation claims associate is responsible for the independent, prompt, and efficient evaluation, investigation, and resolution of assigned claims in accordance with legal statutes, policy provisions, and company guidelines to achieve positive results. Through effective investigation, coordination of medical care, negotiation, and interaction with clients, claimants, medical professionals, attorneys, and insurers ensure that the most advantageous outcomes are achieved, and client resources are utilized in a cost-effective manner. This position also provides technical expertise and serves as an advocate on client claim issues.

Responsibilities:

• The workers' compensation claims associate is responsible for the independent, prompt, and efficient evaluation, investigation, and resolution of assigned claims in accordance with legal statutes, policy provisions, and company guidelines to achieve positive results.
• Through effective investigation, coordination of medical care, negotiation, and interaction with clients, claimants, medical professionals, attorneys, and insurers ensure that the most advantageous outcomes are achieved, and client resources are utilized in a cost-effective manner.
• This position also provides technical expertise and serves as an advocate on client claim issues.
• Promptly investigate all assigned claims from basic to more complex medical and indemnity files with minimal supervision.
• Make timely compensability determinations in accordance with jurisdictional requirements.
• Identify potential fraud indicators and notify management for further investigation.
• Notify excess carriers according to carrier guidelines, provide quarterly updates, and request timely reimbursement.
• Negotiate claims settlements within granted authority and accurately process and track award payments.
• Execute activities according to NY statute, best practices, and claim handling instructions.
• Highly effective verbal and written communication with internal and external parties to support the prompt resolution of claims and return to work in the most cost-effective manner.
• Analyze all Notice of Decisions issued by the Workers’ Compensation Law Judges as it pertains to any individual cases you might be working on, apply the Worker’s Compensation Law Judge’s C-8.1 ruling to any of your outstanding/disputed medical bills.
• Maintain current knowledge of all the forms used by the Workers’ Compensation processes (C-3; C-2F; C-4; C-4.2; C-4AMR; C-4.3; HCFA1500; MG-2; MG-2.1; C4-AUTH; HP-1; HP-2; HP-3; HP-3.1; HPA204; C-8.1; C-8.4; EOR; NOD; NOPCD; RD; AD; MOBPD; NOA; EC-325), rules & regulations (Section 325-1.25; HP-1/HP-J1 processes; Medical Treatment Guidelines & WC Medical Fee Schedule)
• Maintain a proper follow up system for all cases/claims that you previously worked on to ensure timely reimbursement.
• Ensure that you are able to work a minimum of 5 cases per day depending on the case volume and any existing issues, draft excel spreadsheets, submit to claim adjusters, scan and document the case accordingly, ensure that a follow up is being done in a timely manner.
• Maintain your productivity spreadsheet up to date and ensure that your daily work is being documented accordingly.
• Ensure that you review the bills regeneration spreadsheet on the days you are assign for, make sure that all regenerated bills are being processed for resubmission in a timely manner (printing, mailing, documenting).
• Maintain a constant communication with the HP-1 department in PK, inform and submit requests for HP-1 process for any outstanding bills you might be able to identify as being eligible. (HP-1 should be filed no later than 165 days from the DOS and no earlier than 70 days from the bill date).
• Do not resort to only email communications with the claim adjusters/carriers if you are not successful in getting reimbursed, elevate your inquiry to a supervisor, contact the claim adjusters via the telephone and address the issue.
• Maintain a proper system of communication with the WC Claim Department & WC Verification Department, inform them about any cases you encounter that might require any update for billing purposes (Incorrect carrier; change in claim, WCB no#, billing address, etc.)
• Always maintain proper communication with the AR Manager in order to address any arising issues that you might not be able to resolve on your own.
• Maintain current knowledge of New York jurisdictional requirements and applicable case law
• Maintain constant communication and if applicable, identify training areas with global resources to improve efficiency and accuracy

Preferred Experience

• Minimum 2-5 years of workers’ compensation billing experience
• Understanding of no fault & workers’ compensation regulations in NY
• Knowledge of HIPAA guidelines and compliance

We are looking for someone who is/can

• A Fast learner
• Detailed Oriented
• Work independently and efficiently
• Analyze and problem solve independently
• Has superb verbal and written communication skills
• Flexible and can adjust to different situations
• Work under pressure to meet productivity guidelines

Hourly Rate/ Salary is depending on experience.