Workers Compensation Medical Only Claim Specialist - St. Paul, MN

Medical Claims Processor

Our organization works with partner companies to source qualified talent for their open roles. The following position is available to Veterans, Transitioning Military, National Guard and Reserve Members, Military Spouses, Wounded Warriors, and their Caregivers. If you have the required skill set, education requirements, and experience, please follow the next steps.

Salary Range: $45,400.00 - $74,900.00

Target Openings: 1

What Is the Opportunity?

Under moderate to direct supervision, this position is responsible for:

• Reviewing/evaluating, approving and processing Medical Only claims with no lost time beyond statutory waiting period, no salary continuation, and a return to full time work within 90 days if the injured worker is on modified duty and/or total medical paid generally not to exceed $5,000.
• No attorney involvement or ongoing litigation.

As part of the hiring process, this position requires the completion of an online pre-employment assessment. Further information regarding the assessment including an accommodation process, if needed, will be provided at such time as your candidacy is deemed appropriate for further consideration.

What Will You Do?

Identify red flags or other issues, such as medical treatment in excess of 180 days or $5,000 in medical expenses, or 90 days if the injured worker is on modified duty.

Evaluate the need to transfer from medical only to the Investigative Case Unit or Return to Work Unit as appropriate.

Respond to insured and injured worker and provider inquiries as necessary.

Determine causal relatedness and medical necessity of minor medical conditions/treatment through the use of tools/guidelines (medical guidelines, medical position statements, etc.).

Coordinate medical treatment as appropriate:

• Review, approve and make accurate/timely payment of appropriate medical bills and expenses in compliance with State regulations.
• Channel to preferred network as appropriate.
• Complete denials limited to medical issues and communicate denials to impacted parties.
• Identify the need for and engage nurse resource for utilization review when appropriate.
• File appropriate state forms.

In order to perform the essential functions of this job, acquisition and maintenance of Insurance License(s) may be required to comply with state and Travelers requirements. Generally, license(s) must be obtained within three months of starting the job and obtain ongoing continuing education credits as mandated.

Maintain Continuing Education requirements as required.

Perform other duties as assigned.

National Guard Employment Network