Workers' Compensation Compliance Specialist – CMS

Jobtailor; Maine; On-site; USD 60,000 - 90,000; Full time

Job summary

Jobtailor is seeking a detail-oriented CMS Compliance Specialist to manage Section 111 reporting for workers’ compensation claims. You will input CMS data and coordinate with claim representatives to resolve data issues while maintaining thorough documentation.

The role requires strong medical terminology knowledge, three years in workers’ compensation, and proficiency with WCXP/Compliance software and Microsoft Office. A degree or equivalent experience is required.

Qualifications

• Bachelor’s degree or eight years of relevant experience in lieu of a degree.
• At least three years of experience in workers’ compensation claims.
• Strong working knowledge of medical terminology, procedures and treatments.
• Extensive knowledge of workers’ compensation processes and state laws.
• Working knowledge of CMS reporting requirements preferred.
• Proficiency in Microsoft Office (Word and Excel).
• Ability to learn new software applications.
• Excellent organization and time management skills.
• Ability to handle multiple priorities and meet deadlines.
• Ability to communicate effectively, both verbally and in writing, and maintain confidentiality.

Responsibilities

• Ensure company compliance with CMS Section 111 reporting requirements.
• Manage CMS data elements for workers’ compensation claims.
• Verify data points and handle CMS inquiries, including notices and Medicare liens.
• Input Section 111 data into WCXP/Compliance fields for quarterly submissions.
• Maintain ORM diagnoses and TPOC/settlement details for Medicare-eligible workers.
• Update CMS compliance data for ORM termination within statutes of limitations.
• Establish and maintain diary tasks to monitor ORM reporting and termination.
• Maintain knowledge of termination rules across jurisdictions.
• Coordinate and resolve data issues with claim representatives.
• Document Section 111 activity in claim notes.
• Monitor CMS correspondence and Medicare Beneficiary inquiries.
• Direct payments as appropriate.
• Attend business unit, department, and company meetings.
• Assist with company projects and industry conferences.

Skills

CMS Compliance

Workers' Comp Claims

Medical Terminology

Data Management

Microsoft Office

Attention to Detail

Communication

Software Learning

Education

Bachelor’s degree or equivalent experience

Tools

WCXP/Compliance Software

Microsoft Word

Microsoft Excel

Job description

• Ensure company compliance with CMS mandatory insurer reporting requirements under Section 111 of MMSEA
• Manage CMS data elements for workers’ compensation claims
• Verify data points and manage CMS-related inquiries, including conditional payment notices and Medicare Advantage liens
• Research and input Section 111 data elements into WCXP/Compliance fields for quarterly CMS submissions
• Maintain ORM diagnosis and TPOC/settlement details for Medicare-eligible injured workers
• Update CMS compliance claim data elements for ORM termination within jurisdictional statutes of limitations
• Establish and maintain diary tasks to monitor ORM reporting and termination
• Maintain knowledge of statutory rules governing termination of benefits in each jurisdiction
• Coordinate and resolve missing data or errors with claim representatives
• Document Section 111 activity in claim notes
• Monitor and handle CMS correspondence and Medicare Beneficiary inquiries
• Direct payments as appropriate
• Attend business unit, department, and company meetings
• Assist with company projects and participate in insurance-related events, seminars, classes, and conferences

Requirements

• Bachelor’s degree required, or High School Diploma/GED with a minimum of eight years of experience working in a medical, legal, or insurance environment in lieu of the bachelor’s degree
• Minimum of three years of experience in workers’ compensation claims
• Strong working knowledge of medical terminology, common medical procedures, and treatments
• Extensive knowledge of workers’ compensation processes and procedures
• Strong working knowledge of applicable state laws
• Working knowledge of CMS reporting requirements preferred
• Proficiency in Microsoft Office, including Word and Excel
• Ability to learn new computer software applications
• Attention to detail and ability to establish priorities and meet deadlines
• Ability to handle multiple priorities simultaneously
• Excellent organization and time management skills
• Excellent analytical and problem-solving skillsAbility to assess urgency and importance and take appropriate action
• Ability to communicate effectively and professionally verbally and in writing
• Ability to maintain confidential information
• Ability to operate standard office equipment
• Ability to attend insurance and industry/business functions
• Empathic listening skills and ability to build mutual understanding and trust

Core Competencies

Demonstrates expertise in managing CMS compliance and workers' compensation claims, with a strong understanding of medical terminology and applicable state laws. Proficient in data management and reporting, with excellent organizational and analytical skills.

Highest-signal resume keywords

• CMS Compliance Management
• Workers' Compensation Claims Processing
• Medical Terminology Knowledge
• Microsoft Office Proficiency
• Attention to Detail

Hard Skills

• CMS Reporting Requirements
• Data Management
• Workers' Compensation Processes
• Statutory Rules Knowledge
• Analytical Skills

Soft Skills

• Effective Communication
• Time Management
• Problem-Solving
• Empathic Listening
• Organizational Skills

Industry Keywords

• Insurance Compliance
• Medicare Advantage Liens
• Conditional Payment Notices
• ORM Reporting
• Jurisdictional Statutes

Tools & Technologies

• WCXP/Compliance Software
• Microsoft Word
• Microsoft Excel