Claims Payment Specialist I/II
AF Group

Job Info

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SUMMARY:

Claims Payment Specialist I

Primarily responsible for all the following duties Enterprise wide; analysis and entry of detailed wage data into the claim system. May contact employers to obtain missing wage information or to clarify information submitted. Filing required, initial and subsequent jurisdictional filings via EDI, paper and State websites. Resolution of EDI FROI and SROI errors. Contacts include agents, policyholders, claimants, attorneys, and other Claims Department staff.

Claims Payment Specialist II

Primarily responsible for all the following duties Enterprise wide; Analysis and entry of detailed wage data into the claim system. May contact employers to obtain missing wage information or to clarify information submitted. Filing required, initial and subsequent jurisdictional filings via EDI, paper and State websites. Resolution of EDI FROI and SROI errors. Contacts State regulatory offices and EDI vendor to discuss and resolve statutory filing errors. Contacts include agents, policyholders, injured workers, attorneys, and other Claims Department staff.

PRIMARY RESPONSIBILITIES:

• Analyze and enter detailed wage information into the claim system.

• Contact policyholder for wage clarification and to obtain necessary information.

• Analyzes claim system data to determine the input needed into our EDI vendor system.

• Files required initial and subsequent jurisdictional filings via EDI, paper, and State websites.

• Researches and resolves errors received from jurisdictional filings

• Contacts agents, policyholders, and injured workers to verify or gather claim information.

• Prepares form letters and composes general correspondence.

• Keeps apprised of changing rules for data submission from regulatory agencies.

• Works closely with claim handlers to ensure proper data is being transmitted to State Regulatory Offices.

• Reports to State Regulatory Offices in a timely manner.

• Maintains accurate records of State reports generated. Reconciles these records against State benchmark criteria.

Responsibilities of Claims Payment Specialist II:

• Performs all duties under Claims Payment Specialist I.

• Participates on projects as requested.

• Assist with training of Claims Payments Specialist I

• Contacts State regulatory offices and EDI vendor to discuss and resolve statutory filing errors.

This description identifies the responsibilities typically associated with the performance of the job. The percentage of time in any responsibility may vary between positions. Other relevant essential functions may be required.

EMPLOYMENT QUALIFICATIONS:

EDUCATION REQUIRED:

High School Diploma or G.E.D. Advanced training or college level coursework in business, accounting, or insurance. Combination of education and experience may be considered in lieu of additional training or coursework.

EXPERIENCE REQUIRED:

Claims Payment Specialist I

Two years general office experience and one year as a Claims Payment Specialist.

OR

Three years general office experience including two years of insurance or finance related experience or other relevant experience that would provide the necessary skills, knowledge, and abilities.

Claims Payment Specialist II

Three years general office experience and one year as a Claims Payment Specialist I

OR

Four years general office experience including two years in an insurance organization with demonstrated technical knowledge in Workers' Compensation, which provides the necessary skills, knowledge, and abilities.

SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:

Claims Payment Specialist I:

• Basic knowledge of computers and spreadsheet software with data entry ability.

• Basic knowledge of Word Processing software.

• Excellent organizational skills and ability to prioritize work to meet established deadlines.

• Math skills with the ability to use a ten-key calculator.

• Ability to proofread correspondence for accuracy of spelling, grammar, punctuation and format.

• Excellent verbal and written communication skills.

• Demonstrated ability to manage work with minimal direction.

• Demonstrated ability to be an independent thinker to solve issues.

• Ability to enter alpha-numeric data accurately.

• Ability to verify data for accuracy.

• Knowledge of the Workers Compensation Act and Claims process.

• Basic knowledge of medical terminology.

• Knowledge of legal terminology.

• Basic knowledge of spreadsheet software.

• Ability to use reference resources and apply information accordingly.

Additional Skills/Knowledge/abilities of Claims Payment Specialist II:

• All Skills/Knowledge/abilities of Claims Payment Specialist I

• Demonstrated knowledge of the Workers Compensation Act and Claims process.

• Demonstrated knowledge of medical terminology.

• Demonstrated knowledge of legal terminology.

• Demonstrated knowledge of spreadsheet software.

• Demonstrated ability to use reference resources and apply information accordingly.

• Knowledge of spreadsheet software.

ADDITIONAL EDUCATION, EXPERIENCE, SKILLS, KNOWLEDGE AND/OR ABILITIES PREFERRED:

• Additional training, work experience, or course work in workers compensation, insurance or accounting.

• Insurance Institute of America Certification (IIA certification).

• Experience using a document management system with workflows.

• Workers' Compensation Experience.

WORKING CONDITIONS:

Work is performed in an office setting with no unusual hazards.

REQUIRED TESTING:

Claims Payment Specialist I: Basic Windows, Basic Excel, Basic Word, Reading Comprehension, Alpha Numeric, 10-Key, & Math. Proofreading.

Claims Payment Specialist II: Basic Windows, Intermediate Excel, Basic Word, Reading Comprehension, 10-Key, Math, Alpha Numeric, Proofreading.

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