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.
Skills Required
- Knowledge of orthopedic and pain management billing
- Knowledge of state workers’ compensation guidelines
- Knowledge of major insurance carriers
- Experience managing complex workers’ compensation and no-fault claims
- Ability to negotiate with insurance carriers and adjusters
- Ability to prepare and submit claims, appeals, and supporting documentation
Harris healthcare Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about Harris healthcare and has not been reviewed or approved by Harris healthcare.
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Leave & Time Off Breadth — PTO and paid holidays are characterized as generous, with ample time off emphasized. This breadth of time-off options is highlighted alongside favorable impressions of vacation and sick leave.
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Flexible Benefits — Remote-work flexibility and trust to work from home are emphasized, indicating adaptable arrangements for many roles. Flexibility is positioned as a tangible part of the overall package.
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Healthcare Strength — Core coverage includes medical, dental, and vision, along with life and disability insurance and HSA/FSA options. Health plans are often characterized as good, contributing to a solid foundational offering.
Harris healthcare Insights
What We Do
For over 25 years, Harris Healthcare has been rising to the challenge of bringing together the most innovative and sustainable solutions for today’s ever-changing healthcare environment, in order to improve patient care and safety. Each one of our solutions brings organizational efficiencies on its own. Powerful synergies are achieved when multiple solutions are implemented together. The Harris Healthcare portfolio includes the following solutions: ♦ HARRIS Flex - an enterprise-level EHR solution that improves patient safety and clinical workflows. It includes a full complement of applications integrated in one single database, provides solid clinical decision support to your clinicians and helps standardize care while enforcing protocols and best practices at any Healthcare Organization. HARRIS Flex conveys the digital solution’s flexibility and strength. Healthcare organizations are continuously faced with new challenges and situations and require flexible EHR’s that can be rapidly adapted to their evolving clinical practice. Contrary to other EHR solutions which are inflexible and where customizations require costly support from the vendor, HARRIS Flex gives you the freedom to "flex" your EHR as you need it entirely on your own. The enhanced HARRIS Flex solution comes with new functionality including: ♦Flex Telehealth which enables virtual visits directly from within the EHR/EPR, and ♦Flex Clinical Insight which facilitates extraction and analysis of your EHR/EPR data to improve your processes and outcomes. ♦ SynergyCheck – a proactive interface monitoring solution watching over Clinical, Financial and other interfaces 24/7 to ensure data is flowing between systems
