Medical Only Claims Specialist Multistate at AdventHealth

Date Posted: 6/10/2021

Job Snapshot

  • Job Schedule
  • Date Posted:
  • Job ID:
  • Job Family
    Risk Management
  • Travel
  • Shift
    1 - Day

Job Description


Medical Only Claims Specialist AdventHealth Corporate

Location Address: 900 Hope Way Altamonte Springs, FL 32714

Top Reasons To Work At AdventHealth Corporate

  • Great benefits
  • Immediate Health Insurance Coverage
  • Career growth and advancement potential

Work Hours/Shift:

  • Full Time, Monday – Friday

You Will Be Responsible For:

  • Completes three-point contact with employee, employer and medical provider and any witnesses (if known) within 24 hours of receiving claim.
  • Requests wage statement from employer if there is anticipated wage loss
  • Contacts the facility Risk Manager or appropriate management personnel to sequester, tag and secure any equipment as evidence if it is determined that faulty or broken equipment caused the injury.  Notes the claim record of the action taken and who was notified
  • Compensability: Conducts investigation and determines compensability within 14 calendar days and documents same in enhanced notes using enhanced note type “CD” Compensability Decision.  Completes and files any required forms, letters or notices on any claim involving questionable compensability within the time frames specified in each applicable jurisdiction.
  • Requests and obtains medical reports, verifies work status, communicates status to employer and documents same in electronic claim notes
  • Investigates any claim for possible subrogation potential by obtaining applicable report(s), i.e. police report, lease agreements, hold harmless agreements, maintenance reports, air quality report, etc, and pursues recovery by sending a lien letter to appropriate party(s).
  • Engages in proactive medical management of claim by authorizing appropriate medical treatment, promptly making referrals to Specialist and following claim aggressively to MMI.
  • Verifies work status and any specific restrictions and notifies employer of same. Contacts the facility to determine if light duty is available and if restrictions can be accommodated

What You Will Need:

  • 2-3 years’ experience in a workers’ compensation claims department
  • High School
  • Successful completion of Florida Adjuster’s License (All Lines license preferred)
  • Maintain State of Florida All Lines Adjuster License (if applicable) in good standing by completing required continuing education courses (5 hours law & ethics, 5 hours elective)

Job Summary:

This position is responsible for managing work related injury claims in the States of FL, CO, KS, KY, NC, TN, IL, GA, from inception to completion, that do not involve any lost time from work beyond the statutory waiting period under AdventHealth’s self-insured, self-administered workers’ compensation program and according to applicable State workers’ compensation rules and regulations.   The Multi-State Medical Only Claims Specialist conducts a thorough investigation of the claim by performing a 3-point contact with the claimant, employer and medical providers within specified time frames to determine compensability and documents compensability decision in claim notes and files any required denials within statutory time frames.  Requests and obtains medical reports and summarizes all medical treatment in electronic claim notes.  Verifies work status and enters lost days or restricted duty information in Origami and updates as necessary.  Determines, sets and documents justification for medical and expense reserves and updates as necessary.  Maintains contact with the employer/facility representative and provides claim updates.  Investigates claim for any subrogation potential and pursues any possible recovery.  Sets detailed diaries and action plans on all files with target dates for completion of tasks.  Reviews all medical bills, mileage reimbursement requests, pharmacy prescriptions and invoices for appropriateness and relationship to claim.  If appropriate, approves invoices for payment and enters payment information into Origami.   Reviews and completes diaries daily; maintains complete electronic file note documentation for all claim activities.  Reviews medical documentation for referrals to specialists, surgical intervention, etc.   Monitors claims for transfer to Lost Time Claims Specialist if claim becomes litigated and/or claimant begins losing time.   Accurately enters required MMSEA data into Origami to comply with required MMSEA reporting.  Submits applicable state forms within jurisdictional time frames.   Actively participates in providing outstanding customer service and accepts responsibility in maintaining relationship that are equally respectful to all.

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

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