LocationCleveland, OH, US Organization NameGreater Cleveland Regional Transit Authority
About Greater Cleveland Regional Transit Authority
The Greater Cleveland Regional Transit Authority (GCRTA) was formed in 1974 with the mission of providing public transit services to 59 communities and 1.2 million residents of Cuyahoga County. As the largest public transit agency in the State of Ohio, GCRTAs service options include bus, BRT, trolley, paratransit and three rail lines. GCRTA makes connections that empower individuals, neighborhoods, and communities to rise.
We offer a wide range of comprehensive benefits and programs to support the health and wellness of employees and family members including health benefits (medical, dental and vision), a wellness incentive program and participation in the Ohio Public Employee Retirement System (OPERS.)
Position Summary
This role reviews and processes employee injury/occupational disease claims to determine compensability under Ohio Workers' Compensation laws. Reviews and processes short-term disability claims in accordance with the collective bargaining agreements and administrative procedures.
Detailed Description
Scope
Workers compensation claims administration: Determines compensability of incoming workers compensation claims. Provides written claim status to the injured worker and the Ohio Bureau of Workers' Compensation (Bureau). Requests claim allowance hearings on non-allowed claims. Reviews lost time claims and works with vendors to investigate. Prepares and files motions with the Bureau. Makes recommendations as to whether the claim should be referred to outside counsel. Reviews medical proof of disability leave documentation for payment or denial of indemnity benefits. Approves and distributes indemnity benefits in accordance with Ohio law. Reviews and determines the compensability of medical bills. Prepares and distributes bill denial letters. Reviews, approves, and enters allocated expenses. Reviews and responds to treatment and diagnostic testing requests for allowed conditions, necessity, and appropriateness. Conducts investigations of claims, answers questions, and refers employees to the correct GCRTA business partner. Works with other departments to obtain necessary information. Obtains independent medical examinations, prepares narrative reports, copies claim and medical documents, and video evidence for the examining physician
Legal defense preparation: Prepares a hearing worksheet for GCRTA attorneys. File copies of defense medical packets. Labels and files with the Industrial Commission. Schedules court reporters for hearings. Participates in legal defense discussions with attorneys prior to hearings. Provides copies of hearing transcripts to the Industrial Commission. Reviews and processes ordered medical and indemnity payments or denials in compliance with administrative hearing orders. Prepares appeals and provides copies to all parties. Provides recommendations as to whether a reconsideration should be filed with the Industrial Commission. Meets with the legal department to determine if an employers appeal should be filed with the court. Prepare letters. Participates in depositions, requests and attends settlement authority meetings with the Director of Risk Management, pre-trials, final pre-trials, mediations, and General Counsel Trial Brief (GCTB). Attends trials as the client and testifies at trials. Reviews and obtains approval from Legal and Risk Manager on outside legal defense bills. Provides settlement recommendations on claims as well as lawsuits. Solicits settlement authority from the Director of Risk Management.
Short-term disability (STD) claims administration: Reviews and determines eligibility for new short-term disability claims. Updates estimated and actual return-to-work information in Assure Claims. Consults with Director of Risk Management regarding controversial issues with claims, on a case-by-case basis. Provides recommendations on approvals or denials of claims to the Director for specific health conditions and on reconsideration requests from employees with denied STD claims. Upon receipt of full duty releases to return to work, notify appropriate departments with recommendations as to whether a physical return-to-work is needed.
Clerical staff training and guidance: Provides written and verbal instructions to clerical staff and prioritizes job responsibilities based on demand. Provides training and guidance with technical tasks (i.e., ISO & Assure Claims, Ohio Bureau of Workers Compensation website navigation, Industrial Commission website navigation, viewing and making copies of DVDs, etc.).
Department meeting attendance: Attends meetings such as TEAM, Remain at Work, hearing coverage, reserve increase, subrogation interest and calculation worksheet instruction, settlement authority, pre-General Council Trial Briefing (GCTB), Executive Safety Committee (ESC), objection to claim denial, and grievance meetings.
Medicare investigation and reporting: Reviews Centers for Medicare and Medicaid Services (CMS) query responses. Updates Assure claims with Medicare status; reviews Assure Claims with Medicare status; reviews Assure Claims to determine if the person is a Medicare recipient.
Job Requirements
Minimum Requirements
3 to 5 years experience in workers compensation claims processing, insurance, and/or medical billing, etc. An understanding of medical and legal terminology is required.
High school diploma or GED equivalency is required.
Additional Details
Working Conditions
The working conditions described below are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions.
Environmental Conditions
This person will work predominantly in an office-type environment.
Physical Demands
While performing the duties of this job, the employee is regularly required to sit up to 8 or more hours a day. The employee is frequently required to see, hear, and speak. The employee may be required to work at a computer workstation for more than 5 hours a day.
Mental Demands
Reading, studying, focused listening, auditing, inspecting, proofreading, and evaluating are required. Ability to give, receive, and analyze information and prepare written materials. Ability to communicate effectively (verbal and written); interpret policy, procedures, and data.
AN EQUAL OPPORTUNITY/ADA EMPLOYER/DRUG-FREE WORKPLACE
