FROI / Claims Examiner - Paramount
Company: ProMedica Health System
Location: Youngstown
Posted on: January 24, 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. http://www.paramounthealthcare.com.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**Requisition ID:** 71369
Keywords: ProMedica Health System, Youngstown , FROI / Claims Examiner - Paramount, Other , Youngstown, Ohio
Click
here to apply!
|