Multi State Medical Only Claims Specialist

Our promise to you:

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Responsible for managing work-related injury claims from inception to completion under the self-insured, self-administered workers' compensation program according to applicable state regulations. This position conducts thorough investigations by performing a 3-point contact with the claimant, employer, and medical providers to determine compensability and documents decisions in claim notes. Additionally, this role requests and summarizes medical reports, verifies work status, and updates information in Origami as necessary. In addition, this position sets and documents medical and expense reserves, maintains contact with employer representatives, and investigates subrogation potential. Responsibilities for this role include reviewing medical bills, mileage reimbursement requests, pharmacy prescriptions, and invoices for appropriateness, approving invoices for payment, and entering payment information into Origami. This role also monitors claims for transfer to Lost Time Claims Specialist if litigation occurs or the claimant begins losing time, submits state forms within jurisdictional time frames, and ensures compliance with MMSEA reporting requirements.

• Reviews claims over 120 days monthly to ensure appropriate action plans are in place and updates action plans as necessary.
• Conducts thorough investigations of work-related injury claims, including three-point contact with claimant, employer, and medical providers.
• Determines compensability within 14 calendar days and documents decisions in claim notes.
• Requests and summarizes medical reports, verifies work status, and updates information in electronic claim notes.
• Sets and documents initial and subsequent medical and expense reserves based on anticipated expenditures.
• Manages proactive medical treatment authorization, referrals to specialists, and follows claims to Maximum Medical Improvement (MMI).
• Reviews and approves or denies medical bills, mileage reimbursement requests, pharmacy prescriptions, and invoices within jurisdictional time frames.
• Investigates subrogation potential by obtaining applicable reports and pursues recovery by sending lien letters to appropriate parties.
• Transfers claims to Lost Time Claims Specialist if litigation occurs or claimant begins losing time, and documents the transfer in claim notes.
• Submits required state forms within jurisdictional time frames and ensures compliance with MMSEA reporting requirements.
• Maintains timely, complete, and accurate electronic claim notes and files on a diary system.
• Completes closing activities when claims are resolved, including changing claim status and freezing payments.
• Performs other duties as assigned.

• Basic web navigational and computer skills required [Required]
• Origami, Riskmaster, Microsoft Office Suite, Mitchell and AWPRx software programs [Required]
• Medical terminology [Required]

• High School Grad or Equivalent [Required]
• Bachelor's [Preferred]

• 2+ years of experience in a workers compensation claims department [Required]

• 6-20 All-Lines Adjuster License [Required]

Certain positions are subject to Florida Level 2 background screening, including fingerprinting, as required by state law.

Applicants may review general information about Florida’s background screening requirements at the Florida Care Provider Background Screening Clearinghouse:
https://info.flclearinghouse.com/

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.