Workers Compensation Specialist

UNITE HERE HEALTH serves over 200,000 workers and their families in the hospitality and gaming industry nationwide. Our desire to be innovative and progressive drives us to develop impactful programs and benefits designed to engage our participants in managing their own health and healthcare. Our vision is exciting and challenging. Please read on to learn more about this great opportunity!The Workers Compensation Specialist will coordinate the workers’ compensation program that allows potential work-related claims to be paid while the Participant follows the state workers’ compensation process. Recovery dollars are then deemed to be work-related from providers when the workers compensation process in complete. This position requires patient and participant communication skills to explain and support participant enrollment in the program, TPA system knowledge and accurate record keeping, follow up with staff, participants, provider offices, TPA and vendors, and union communication requests. ESSENTIAL JOB FUNCTIONS AND DUTIES Receive, review, and take appropriate action on claims related to work related injury claims received from the TPA, Fund, Union, NHS, or Workers’ Compensation Attorney Communicate with the employees and/or their Attorney, provide guidance during the appeal process (1st and 2nd level appeal), follow up with letters and phone calls, and document process and steps for each case Obtain and distribute accordingly the medical records and document needed to proceed with the case Provide directives to the TPA on next steps — pay claims or recover on paid claims according to Worker’s Compensation final Case determination Assist employees with continuity of care access-related inquiries during the two levels of the appeal process Track and submit necessary reports on workers’ compensation cases to the Fund’s Leadership Manage the mail process in a timely manner to ensure patient is not disenfranchised by a missed workers compensation mandated deadline Maintain a sense of timeliness in the handling of priority cases and reduction requests such as completing case follow ups within timeline guidelines Manage difficult calls and return follow-up calls within 24 hours Treat referral of settled cases as priority and refer to the TPA within Fund guidelines (usually 24 hours) Comply with Federal/States mandates as applied to Workers’ Compensation Cases Exemplifies the Fund’s values in leading and fostering a respectful, trusting, and engaged culture of inclusion and engagement ESSENTIAL QUALIFICATIONS 4 ~ 6 years of related experience within Nevada state workers’ compensation claims cases Associate’s degree or equivalent work experience, preferred Experience with interpretation of benefit plans, including an understanding of limitations, exclusions, and schedule of benefits Working knowledge and experience in medical claims adjudication, preferably in a multi-employer environment Understanding of Medicare, Medicaid, ACA, DOL regulations, ERISA and HIPAA Intermediate level MS Office and MS Excel skills Manage competing deadlines and multiple projects in a fast-paced environment Excellent communication skills, with the ability to communicate effectively with vendors, state agencies, participants, union staff, and Fund staff and leadership Ability to demonstrate good judgment and have excellent critical thinking and problem-solving skills Ability to work independently with minimal supervision in a fast-paced environment Salary range for this position: Salary $58,300 – $72,900. Actual base salary may vary based upon, but not limited to: relevant experience, qualifications, expertise, certifications, licenses, education or equivalent work experience, time in role, peer and market data, prior performance, business sector, and geographic location.Work Schedule (may vary to meet business needs): Monday~Friday, 7.5 hours per day (37.5 hours per week) as a hybrid employee, 8 — 4pm (PT).We reward great work with great benefits, including but not limited to: Medical, Dental, Vision, Paid Time-Off (PTO), Paid Holidays, 401(k), Short- & Long-term Disability, Pension, Life, AD&D, Flexible Spending Accounts (healthcare & dependent care), Commuter Transit, Tuition Assistance, and Employee Assistance Program (EAP).#LI-Hybrid Unite Here Health

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