Claims Examiner Specialist - Paramount

Paramount Health Care, a ProMedica Health Plan, offers insurance products across six Midwest states. This Ohio-based company, headquartered in Toledo, has more than 685 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 at paramounthealthcare.com.

REPORTING RELATIONSHIPS/SUPERVISORY RESPONSIBILITIES

This position does not support direct reports and reports to the department manager.

POSITION SUMMARY

Responsible for providing workers’ compensation third party administration claims management to Stated-Funded and self-insured employers.

ACCOUNTABILITIES

• Provide professional customer service in the administration and management of employer workers’ compensation programs in Ohio and providing risk control through aggressive claims management.
• Proper analyzation of claims exposure in order to set/review reserves to maximum probably exposure for State-Funded and Self-Insured Employers.
• Investigates, evaluates and settles claims while verifying and analyzing data used in accordance with BWC and PPS policies and procedures.
• Determine proper involvement of vendor services such as medical case management, vocational rehabilitation services, medical and pharmaceutical reviews, legal and surveillance to ensure the effective cost containment of expenses on claims.
• Assist legal counsel in preparation of Workers’ Compensation cases and attendance at Workers’ Compensation Hearings if necessary.
• Participate in monthly/quarterly claim review with Employers providing detailed reports and claim reviews.
• Works closely with all parties to the claim for successful resolution to the claim.
• Markets PPS services when appropriate and focuses on continued client retention.    
• Trains new staff members as necessary
• Contributes to quality assurance activities and quality improvement initiatives.
• Participates in other departmental activities as directed by the department manager/director.

REQUIRED QUALIFICATIONS

Education: High School Diploma or equivalent.

Skills:

1. Previous workers’ compensation experience.
2. Knowledge of medical and legal terminology.
3. Demonstrated ability to utilize Microsoft Word, Excel and other computer programs proficiently.
4. Proven ability to work in an organized and methodical manner to ensure department deadlines are met.
5. Excellent communication skills.

PREFERRED QUALIFICATIONS

Education: Associates degree in Risk/Claims Management or related field.

Skills:  Previous experience in a paralegal office environment preferred.

ProMedica is a mission-based, not-for-profit integrated healthcare organizational headquartered in Toledo, Ohio.  For more information, please visit www.promedica.org/about-promedica

Qualified 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.org

Equal Opportunity Employer/Drug-Free Workplace