What are the responsibilities and job description for the FROI / Claims Examiner - Paramount position at ProMedica?
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.
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.
Job Requirements
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-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
Employee Exemption Type
Non-Exempt
Job Type
Full Time
Budgeted Hours / Pay Period
80
Shift Type
Days
Shift Hours
8 hours
Weekends
N/A
On-call Requirements
Call Not Required
Additional Schedule Details
This position can be filled in any one of Paramount's multiple offices. Paramount has 5 office locations: Wheeling, West Virginia Cleveland, Ohio Columbus, Ohio Toledo, Ohio Youngstown, Ohio
