WC Medical Claims Specialist

WC Medical Claims Specialist -PN: 20068786, 20068762, 20068322, 20068757 & 20068785 (2500057E)

WC Medical Claims Specialist -PN: 20068786, 20068762, 20068322, 20068757 & 20068785

(2500057E)

Organization: Workers' Compensation

Agency Contact Name and Information: Mia Truss-Davis - HCM Sr. Analyst: ...

Unposting Date: Jul 17, 2025, 9:59:00 PM

Work Location: William Green Building 30 West Spring Street Columbus 43215-2256

Primary Location: United States of America-OHIO-Franklin County-Columbus

Compensation: $24.16 - $30.55

Schedule: Full-time

Work Hours: 40

Classified Indicator: Classified

Union: OCSEA

Primary Job Skill: Claims Examination

Technical Skills: Business, Claims Examination, Medical

Professional Skills: Analyzation, Attention to Detail, Ethics and Values, Time Management, Written Communication

Agency Overview

A Little About Us:

With roughly 1,500 employees in seven offices across Ohio, BWC is the state agency that cares for Ohio workers by promoting a culture of safety at work and at home and ensuring quality medical and pharmacy care is provided to injured workers.

For Ohio employers, we provide insurance policies to cover workplace injuries and safety and wellness services to prevent injuries.

Our Culture:

BWC is a dynamic organization that offers career opportunities across many different disciplines. BWC employees strive to maintain an inclusive workplace. We begin by being an equal opportunity employer. Employees can participate in and lead employee resource groups, participate in online forums discussing society's impact on our services and workplace, and learn about how different perspectives can improve leadership skills.

Our Vision:

To transform BWC into an agile organization driven by customer success.

Our Mission:

To deliver consistently excellent experiences for each BWC customer every day.

Our Core Values:

One Agency, Personal Connection, Innovative Leadership, Relentless Excellence.

Job Description

BWC's core hours of operation are Monday-Friday from 8:00am to 5:00pm, however, daily start/end times may vary based on operational need across BWC departments. Most positions perform work on-site at one of BWC's seven offices across the state. BWC offers flex-time work schedules that allow an employee to start the day as early as 7:00am or as late as 8:30am. Flex-time schedules are based on operational need and require supervisor approval.

What You'll Be Doing:

Performs initial/subsequent claims investigation and determinations for Medical-Only claims within prescribed timeframes.

Reviews and gathers information necessary to identify the claim severity. Will staff more complex claims with supervisor, team nurses, and field service office staff.

Through phone contacts, written correspondence, and investigation, makes initial and subsequent claim determinations and issues orders as appropriate.

Sends Due Process notifications; reviews claim for supporting medical; refers claim for medical review if necessary and issues appropriate BWC orders.

Create Case for referral to the Industrial Commission of Ohio for a decision as needed.

Processes and maintains claim information, medical and legal documents within prescribed timeframes, and records information in system.

Updates and maintains tasks list. Responds orally and in writing to requests from injured workers, employers, providers, legal representatives, managed care organizations, and legislators.

Documents claim transactions and activities in claim management system notes and establishes claim tasks for ongoing claim management.

What our employees have to say:

BWC conducts an internal engagement survey on an annual basis. Some comments from our employees include:

BWC has been a great place to work as it has provided opportunities for growth that were lacking in my previous place of work.

I have worked at several state agencies and BWC is the best place to work.

Best place to work in the state and with a sense of family and support.

I love the work culture, helpfulness, and acceptance I've been embraced with at BWC.

I continue to be impressed with the career longevity of our employees, their level of dedication to service, pride in their work, and vast experience. It really speaks to our mission and why people join BWC and then retire from BWC.

If you are interested in helping BWC grow, please click this link to read more, and then come back to this job posting to submit your application!

Why Work for the State of Ohio

At the State of Ohio, we take care of the team that cares for Ohioans. We provide a variety of quality, competitive benefits to eligible full-time and part-time employees*. For a list of all the State of Ohio Benefits, visit our Total Rewards website! Our benefits package includes:

Medical Coverage

Free Dental, Vision and Basic Life Insurance premiums after completion of eligibility period

Paid time off, including vacation, personal, sick leave and 11 paid holidays per year

Childbirth, Adoption, and Foster Care leave

Education and Development Opportunities (Employee Development Funds, Public Service Loan Forgiveness, and more)

Public Retirement Systems (such as OPERS, STRS, SERS, and HPRS) & Optional Deferred Compensation (Ohio Deferred Compensation)

*Benefits eligibility is dependent on a number of factors. The Agency Contact listed above will be able to provide specific benefits information for this position.

Qualifications

3 courses or 9 mos. trg. or 9 mos. exp. in English composition or grammar; 3 courses or 9 mos. trg. or 9 mos. exp. in accounting, bookkeeping or general business mathematics; 3 courses or 9 mos. trg. or 9 mos. exp. in communication or public speaking or 9 mos. exp. involving contact with injured workers, employers, legislators, providers or their representatives & public; successful completion of one typing course or demonstrate ability to type 35 words per minute.

-Or 12 mos. exp. as Workers' Compensation Claims Assistant, 16720, (i.e., providing assistance to claims field operations team or medical claims team by ensuring all documents are complete, accurate & in compliance with bureau of workers' compensation procedures, determining allowances using code manual ICD/CPT & taking appropriate action on self-insured claims or referring documents for further action by claims team member, reconstructing lost claim files or assigning claim numbers & updating claim information & managing caseload of self-insured medical & disability claims to ensure compliance with Ohio Workers' Compensation Law).

-Or 12 mos. exp. as BWC Customer Service Representative, 64451, (i.e., providing information/assistance to &/or answering complaints, questions &/or telephone inquiries &/or written correspondence from customers pertaining to claims status or procedures, reviewing & analyzing claims, referring customers to available community services, & conducting telephone interviews with citizens reporting fraud allegations). Note: Classifications may require use of proficiency demonstration to determine minimum class qualifications for employment.

-Or equivalent of Minimum Class Qualifications For Employment noted above.

Job Skills: Claims Examination

Major Worker Characteristics:

Knowledge of: workers' compensation laws, policies & procedures*; eligibility criteria & procedures used for processing workers' compensation medical only claims*; principles of customer service; public relations; English grammar & spelling; oral & written business communication; fundamental mathematics (e.g. addition, subtraction, multiplication, division, fractions, decimals & percentages); Workers' Compensation standard business practices*; interviewing techniques; internet search engines & navigation; medical terminology; medical diagnosis coding*; Industrial Commission processes*;

Skill in: operation of a personal computer; typing; use of Microsoft Office software (e.g., Outlook, Word, Excel, Access, PowerPoint); use of BWC-specific software (e.g., Workers' Compensation claims management system , BWC Web Site, SharePoint)*; operation of office machinery (e.g. calculator, printer, copier, fax, phone); communication skills (e.g., listening, writing, reading, phone etiquette); use of internet;

Ability to: define problems, collect data, establish facts, & draw valid conclusions; read, access & understand medical reference manuals & reports; gather, collate & classify information about data, people, or things; communicate effectively and professionally; communicates on sensitive information and inquiries with injured workers, employers, providers or their representatives & the public; multitask by utilizing good organizational skills & time management; answer routine & technical inquiries from injured workers, employers, medical providers & public*; make proper referrals (within agency & external sources)*; diffuse potentially volatile situations; present information to others; work with a team; develop good rapport with internal and external customers; utilize ICD coding tools*; generate properly formatted business correspondence; prioritize caseload based on performance goals*; interpret Data Warehouse reports*.

(*) Developed after employment.

Supplemental Information

EEO & ADA Statement:

The State of Ohio is an Equal Employment Opportunity Employer and prohibits discrimination and harassment of applicants or employees due to protected classes as defined in applicable federal law, state law, and any effective executive order.

The Ohio Bureau of Workers' Compensation is committed to providing access and reasonable accommodation in its employment opportunities pursuant to the Americans with Disabilities Act and other applicable laws. To request a reasonable accommodation due to disability, please contact ADA Coordinator Kathleen Bourke at ... or by email to: ....

BWC OCSEA Selection Rights:

This position shall be filled in accordance with the provisions of the OCSEA Collective Bargaining Agreement. BWC bargaining unit members have selection rights before non-bargaining unit members. All other applications will only be considered if an internal bargaining unit applicant is not selected for this position.

Salary Information:

Hourly wage is expected to be paid at step 1 of the pay range associated with the position for candidates who are new employees of the state. Current employees of the state will be placed in the appropriate step based on any applicable union contract and/or requirements of the Ohio Revised Code. Movement to the next step of the pay range (a roughly 4% increase) will occur after six months, assuming job performance is acceptable. Thereafter, an employee will advance one step in the pay range every year until the highest step of the pay range is reached. There may also be possible cost of living adjustments (COLA) and longevity supplements begin after five (5) years of state service.

Educational Transcripts:

For any educational achievements to be considered during the screening process, you must at least attach an unofficial transcript that details the coursework you have completed.

All applicants must submit an Ohio Civil Service Application using the online Ohio Hiring Management System. Paper applications will not be accepted.

Background Check:

Prior to an offer of employment, the final applicant will be required to sign a background check authorization form and undergo a criminal background check. Criminal convictions do not necessarily preclude an applicant from consideration for a position.

ADA Statement

Ohio is a Disability Inclusion State and strives to be a model employer of individuals with disabilities. The State of Ohio is committed to providing access and inclusion and reasonable accommodation in its services, activities, programs and employment opportunities in accordance with the Americans with Disabilities Act (ADA) and other applicable laws.

Drug-Free Workplace

The State of Ohio is a drug-free workplace which prohibits the use of marijuana (recreational marijuana/non-medical cannabis). Please note, this position may be subject to additional restrictions pursuant to the State of Ohio Drug-Free Workplace Policy (HR-39), and as outlined in the posting.