Workers’ Compensation Claims Examiner - Detail-Driven

State of Ohio; Cambridge (OH); On-site; USD 3,656,000 - 4,757,000; Full time

Job summary

Ohio Bureau of Workers’ Compensation (BWC) in Cambridge, OH is seeking a WC Claims Specialist to manage a busy caseload of workers’ compensation claims. You will communicate with internal/external stakeholders, perform timely investigations, determine entitlement to benefits, and coordinate with MCOs, TPA, and employers to support return-to-work plans.

Core duties include handling TT and Wage Loss payments, liaising with legal representatives, and ensuring compliance with Ohio law and BWC

Qualifications

• 36 mos. exp. in position requiring evaluation of medical or public assistance benefits (e.g., health insurance benefits, disability benefits, workers’ compensation benefits, unemployment benefits, public assistance benefits for food subsidies) in order to determine eligibility for benefits, approve or deny claims, resolve benefit-related disputes, calculate benefit payments, &/or perform similar benefit-related duties.
• Or completion of undergraduate core coursework in business, humanities, social & behavioral science, education or related field; 12 mos. exp. in position requiring evaluation of medical or public assistance benefits (e.g., health insurance benefits, disability benefits, workers’ compensation benefits, unemployment benefits, public assistance benefits for food subsidies) in order to determine eligibility for benefits, approve or deny claims, resolve benefit-related disputes, calculate benefit payments &/or perform similar benefit-related duties.
• Or 24 mos. exp. as Workers’ Compensation Claims Assistant, 16720 &/or BWC Customer Service Representative, 64451, &/or BWC Employer Service Representative, 63521.
• Or 12 mos. exp. as Workers’ Compensation Medical Claims Specialist, 16721.
• Or any combination of at least 36 mos. exp. in position requiring evaluation of medical or public assistance benefits &/or as Workers’ Compensation Claims Assistant, 16720, &/or as BWC Customer Service Representative, 64451 &/or as BWC Employer Service Representative, 63521.

Responsibilities

• Manages a caseload of Workers’ Compensation claims: Communicates, coordinates & collaborates with internal & external stakeholders (e.g. Disability Management Coordinator [DMC], Medical Service Specialist [MSS], Managed Care Organization [MCO], Employer Management [EM] team, Safety & Hygiene, injured workers, employers, Third Party Administrators [TPA] & rehabilitation personnel) in order to set return to work expectations.
• Performs initial/subsequent claims investigation & determination within prescribed timeframes: Contacts parties involved in claim process; completes investigation during initial claim development to determine information pertinent to management of claim (e.g., jurisdiction, coverage, causality, compensability, claim data accuracy, current work status of claimant, job description, salary continuation, physical demands of job, & work history of claimant).
• Processes various types of compensation ranging from Temporary Total (TT) Compensation, Wage Loss, Permanent Partial and Percentage of Permanent Partial, Living Maintenance, to Lump Sum Advancement requests; addresses subsequent requests by parties to claim via due process notification, investigation, BWC orders & referrals to the Industrial Commission (IC) of Ohio
• Responds to customer inquiries
• Follows Ohio Revised Code and BWC policies and procedures
• Communicates with legal representatives, employers, claimants, etc.

Skills

Claims Examination

Customer Service

Attention to Detail

Critical Thinking

Teamwork

Time Management

Written Communication

Tools

Microsoft Office

BWC Claims Management System

Intrafin

FMS fraud system

Job description

Ohio Bureau of Workers’ Compensation (BWC) in Cambridge, OH is seeking a WC Claims Specialist to manage a busy caseload of workers’ compensation claims. You will communicate with internal/external stakeholders, perform timely investigations, determine entitlement to benefits, and coordinate with MCOs, TPA, and employers to support return-to-work plans.

Core duties include handling TT and Wage Loss payments, liaising with legal representatives, and ensuring compliance with Ohio law and BWC