FROI / Claims Examiner - Paramount
Company: ProMedica
Location: Youngstown
Posted on: January 18, 2023
Job Description:
ProMedica's health plan, Paramount Insurance, offers health
insurance products across six Midwest states. Paramount is an
Ohio-based health insurance company, headquartered in Toledo. The
organization has more than 800 employees dedicated to serving their
health plan members.Paramount offers Medicare Advantage and
Marketplace Exchange health plans for individuals and families.
Paramount maintains accreditation by the National Committee for
Quality Assurance (NCQA) for their HMO and Medicare Advantage
products.In addition, Paramount has a full complement of insurance
products for employers of any size, including medical, dental,
vision and workers' compensation, as well as vocational
rehabilitation, life-care planning, and wellness.As a part of
ProMedica, Paramount is driven by ProMedica's mission to improve
your health and well-being. ProMedica has been nationally
recognized for its advocacy programs and efforts to address social
determinants of health. Paramount strives to provide an exceptional
experience to every member. For more information about Paramount,
please visit our website. -.Basic Purpose:Non-case management staff
responsible for supporting the case management process. Always
works under direct supervision of a Nurse Case Manager and does not
make clinical judgement.Primary Duties:
- Establish a three-point contact between the injured worker,
employer, and provider to gather information needed to file a claim
with Ohio Bureau of Workers' Compensation (BWC).
- Communication and collaboration with injured workers (IW),
employers, providers, third party administrators (TPA), attorneys,
and the BWC to obtain a safe return to work (RTW) while working
within BWC designated guidelines.
- Effectively apply the MCO process including completion of
appropriate first report of injury documentation, medical
management templates, and documentation of potential barriers to a
successful RTW within the scope of the non-clinical position.
- Process all treatment requests (C-9s) within 72 hours to
provide the IW with the treatment medically necessary and
appropriate for the Allowed Conditions. Staff C-9 requests with the
Nurse Case Manager or Medical Director as needed.
- Follow up with the providers to obtain current treatment plans,
results of diagnostics, and RTW goals. Obtain modified duty
availability from employers and communicate to providers and IWs.
Obtain restrictions to a full RTW from provider and communicate to
the employer and IW.
- Properly refer all cases to the Nurse Case Manager when
appropriate as well as utilize the RN for all clinical issues
pertaining to the IW's claims. Identify IWs who are potential
vocational rehabilitation candidates and complete the referral
process.
- Adherence to all Health Management Solutions (HMS) policies and
URAC standards as well as all Confidentiality policies and
guidelines. Ensure that all documentation is current, accurate, and
complete including remaining current with all diaries. Follow all
HMS and BWS guidelines for appropriate medical management of claims
and participate in educational and informational seminars as
needed.
- Completion of team peer-to-peer FROI/CE audits quarterly.
- Other duties as assigned.General Information/Qualifications:
- High School/GED Certificate
- 2 years managed care experience preferred
- Exceptional written, telephonic, and oral communication (public
speaking), leadership, problem-solving, interpersonal, and
organizational skills required. Ability to coordinate and organize
multiple priorities.
- Excellent knowledge of medical terminology
- Experience using Microsoft Office programs, especially Excel,
Word, PowerPoint, and Access.ProMedica is a mission-based,
not-for-profit integrated healthcare organizational headquartered
in Toledo, Ohio. - -For more information, please visit
-www.promedica.org/about-promedicaQualified applicants will receive
consideration for employment -without regard to race, color,
national origin, ancestry, religion, -sex/gender (including
pregnancy), -sexual orientation, gender identity or gender
expression, age, physical or mental disability, military or
protected veteran status, citizenship, familial or marital status,
genetics, or any other legally protected category. In compliance
with the Americans with Disabilities Act Amendment Act (ADAAA), if
you have a disability and would like to request an accommodation in
order to apply for a job with ProMedica, please contact
-employment@promedica.orgEqual Opportunity Employer/Drug-Free
Workplace
Keywords: ProMedica, Youngstown , FROI / Claims Examiner - Paramount, Other , Youngstown, Ohio
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