Workers' Compensation Compliance Specialist (CMS) - Eastern Alliance

Proassurance; Lancaster (Lancaster County); Hybrid; USD 58,000 - 95,000; Full time

Job summary

ProAssurance is seeking a Compliance Specialist to support the Eastern Alliance workers' compensation line. The role focuses on CMS Section 111 reporting, ORM/TPOC data management, and CMS correspondence handling.

This hybrid position reports to an Eastern Alliance office location about 2 days per month. Qualified candidates will have a bachelor's degree (or HS diploma with 8+ years in medical/legal/insurance), at least 3 years in workers' compensation, and strong MS Office skills.

Qualifications

• Bachelor's degree required; HS diploma with 8+ years in medical/legal/insurance can replace.
• Minimum 3 years' workers' compensation claims experience.
• Strong medical terminology and procedures knowledge.
• CMS reporting knowledge preferred.

Responsibilities

• Input Section 111 data elements into CMS/WCXP for quarterly CMS submissions.
• Maintain ORM termination diary and ensure timely ORM/TPOC reporting.
• Resolve missing data with claim representatives and document activity.
• Monitor CMS correspondence and Medicare beneficiary inquiries; direct appropriate payments.
• Maintain current CMS Section 111 requirements knowledge.
• Attend business unit, department, and company meetings.
• Support projects and participate in insurance-related events.

Skills

CMS reporting

Data analysis

Attention to detail

Communication

Time management

Education

Bachelor's degree

High School Diploma with 8+ years experience

Tools

WCXP

Microsoft Excel

Microsoft Word

Job description

An exciting opportunity exists to join the ProAssurance family of companies! Our mission is powerful and simple: We protect others. Choosing a place to apply your talents is an important decision for anyone. You have plenty of options. Why choose ProAssurance? At ProAssurance, we sell a pledge, and that pledge is delivered by our team members. We are seeking individuals who value integrity, leadership, relationships, and enthusiasm-and want to build their career with a great company where they can be their authentic self and feel valued, recognized, and rewarded for their contributions. ProAssurance specializes in healthcare professional liability, products liability for medical technology and life sciences, legal professional liability, and workers' compensation insurance. We are an industry-leading specialty insurer, with job opportunities in much of the contiguous United States.

The internal title for this position is Compliance Specialist.

This position supports our workers' compensation line of business, Eastern Alliance, and is hybrid, reporting to any of our Eastern Alliance office locations approximately 2 days per month. The primary responsibility of this position is to ensure the Company’s compliance with the CMS mandatory insurer reporting requirements for Section 111 of the Medicare, Medicaid, and SCHIP Extension Act (MMSEA) Medicare Secondary Payer Act under the direction of management.

Responsibilities of this position include managing all CMS data elements aspects for WC claims, including verifying data points and managing CMS related inquiries, including, but not limited to, conditional payment notices (CPNs) and Medicare Advantage liens under moderate supervision, following established Company requirements and procedures for reporting Section 111 for Ongoing Responsibility for Medicals (ORM) and Total Payment Obligation to Claimants (TPOC) timely and accurately.

What you’ll do:

• 40% - Timely, accurately, and in accordance with statutory guidance and timelines, conduct research and inputs required Section 111 data elements into WCXP/Compliance fields required for quarterly submission to CMS. Ongoing Responsibility for Medical (ORM) accepted ICD code/diagnoses, and Total Payment Obligation to Claimant (TPOC)/settlement details on claims for Medicare eligible Injured Workers.
• 25% - Proactively manage and update the WCXP CMS Compliance claim data elements required for termination of Ongoing Responsibility for Medical (ORM) within each jurisdiction's statute of limitations for medicals, and in compliance with the CMS Non-group health plan (NGHP) reference guide. Establish and maintain a diary task to monitor timely and accurate ORM and ORM termination for Medicare eligible claim files. Understand and maintain current knowledge and expertise on the statutory rules around termination of benefits in each jurisdiction.
• 10% - Coordinate and resolve missing data elements or errors with the claim representative. Document the Section 111 activity in a claim note in accordance with best practices.
• 15% - Monitor and handle incoming CMS correspondence and Medicare Beneficiary inquiries related to CMS development letters, conditional payment liens notices, and Medicare Advantage lien(s) under the direction of management. Direct the issuance of payments as appropriate.
• 5% - Maintain knowledge of CMS requirements for Section 111 reporting
• 5% - Attends business unit, department, and company meetings.
• 5% - Assist with Company projects assigned and continue professional growth and development through attendance and participation in insurance related events/functions, seminars, classes, and conferences.

What we’re looking for:

• Bachelor's degree is required; a High School Diploma/GED with a minimum of eight years of experience working in a medical, legal, or insurance environment can replace the bachelor's degree requirement.
• A 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, with strong working knowledge of applicable state laws.
• Working knowledge of CMS reporting requirements preferred.
• Proficiency in Microsoft Office computer applications, including Word and Excel, and ability to learn new computer software applications.
• Attention to detail in processing all information, establishing priorities, and meeting deadlines.
• Ability to handle multiple priorities simultaneously.
• Excellent organization and time management skills.
• Excellent analytical and problem-solving skills, including analyzing and interpreting large amounts of information and formulating logical, objective conclusions based upon the facts.
• Ability to assess the urgency and importance of a situation and take appropriate action.
• Empathic listener with the ability to listen and respond to another person in a way that engenders mutual understanding and trust.
• Ability to communicate effectively and professionally both verbally and in writing with various constituencies and at all levels, both in and outside of the organization, including agency partners, customers, injured workers, and providers.
• Ability to maintain confidential information.
• Ability to operate standard office equipment including, but not limited to copiers, printers, etc.
• Ability to attend insurance and industry/business functions to promote and present a positive image of the Company.

We are committed to providing a dynamic and inclusive environment where everyone can do their best work and grow personally and professionally.

Position Salary Range$57,575.00 - $95,008.00 The salary range displayed represents the entirety of the pay grade for this position. Most candidates will start in the bottom half of the range. Factors that may be used to determine your actual salary include your specific skills, how many years of experience you have, your location and comparison to other team members already in this role. Build your career with us and enjoy access to a best-in-class benefits program.