Job Summary
The Senior Workers' Compensation Specialist, Complex Claims, verifies workers' compensation (WC) carrier and claim information, then manages billing, follow-up, denials and appeals through to payment. In this senior-level role, the Specialist works WC and No-Fault accounts autonomously, negotiates with carriers and adjusters, and flags trends that affect reimbursement. The Specialist also works with leadership and their direct manager to improve workflows and streamline operations. The ideal candidate knows orthopedic and pain management billing, state WC guidelines and major insurance carriers.
Essential Functions
- Verifies workers' compensation carrier and claim information before and during billing, including:
- Confirming the correct WC carrier, claim number, date of injury, employer and adjuster contact details.
- Confirming claim status (accepted, pending, denied or closed) and the accepted body parts / injuries.
- Obtaining and documenting authorizations and referrals for scheduled services.
- Using carrier phone lines, adjusters, employer contacts and web portals, and noting all findings in the patient account.
- Initiates contact with WC insurance carriers, adjusters and web portals on all outstanding bills, updating accounts and noting them as worked.
- Prepares and submits claims, verifying accuracy and correcting errors before submission.
- Prepares appeals with all required documentation and submits them to the insurance carrier within filing deadlines.
- Corrects inaccurate demographic and insurance information for insurance and patient billing.
- Alerts the team and managers to trends, recurring denials or billing issues as they arise.
- Works with leadership and their direct manager to find process gaps, streamline workflows and improve reimbursement and collection outcomes, including creating, updating and maintaining Standard Operating Procedures (SOPs) for workers' compensation and No-Fault processes.
- Mentors and trains less-experienced team members, and serves as the go-to expert on workers' compensation and No-Fault billing.
- Takes ownership of complex and escalated accounts through to resolution, using independent judgment within department policies.
- Posts payments and documents payment records and issues promptly.
- Scans and uploads documents and medical records for claims processing and medical records requests.
Originally posted on