FROI / Claims Examiner - Paramount
Posted on: January 20, 2023
ProMedica's health plan, Paramount Insurance, offers health
insurance products across six Midwest states. Paramount is an
Ohio-based health insurance company, headquartered in Toledo. The
organization has more than 800 employees dedicated to serving their
health plan members.
Paramount offers Medicare Advantage and Marketplace Exchange health
plans for individuals and families. Paramount maintains
accreditation by the National Committee for Quality Assurance
(NCQA) for their HMO and Medicare Advantage products.
In addition, Paramount has a full complement of insurance products
for employers of any size, including medical, dental, vision and
workers' compensation, as well as vocational rehabilitation,
life-care planning, and wellness.
As a part of ProMedica, Paramount is driven by ProMedica's mission
to improve your health and well-being. ProMedica has been
nationally recognized for its advocacy programs and efforts to
address social determinants of health. Paramount strives to provide
an exceptional experience to every member. For more information
about Paramount, please visit our website.
Non-case management staff responsible for supporting the case
management process. Always works under direct supervision of a
Nurse Case Manager and does not make clinical judgement.
- Establish a three-point contact between the injured worker,
employer, and provider to gather information needed to file a claim
with Ohio Bureau of Workers' Compensation (BWC).
- Communication and collaboration with injured workers (IW),
employers, providers, third party administrators (TPA), attorneys,
and the BWC to obtain a safe return to work (RTW) while working
within BWC designated guidelines.
- Effectively apply the MCO process including completion of
appropriate first report of injury documentation, medical
management templates, and documentation of potential barriers to a
successful RTW within the scope of the non-clinical
- Process all treatment requests (C-9s) within 72 hours to
provide the IW with the treatment medically necessary and
appropriate for the Allowed Conditions. Staff C-9 requests with the
Nurse Case Manager or Medical Director as needed.
- Follow up with the providers to obtain current treatment plans,
results of diagnostics, and RTW goals. Obtain modified duty
availability from employers and communicate to providers and IWs.
Obtain restrictions to a full RTW from provider and communicate to
the employer and IW.
- Properly refer all cases to the Nurse Case Manager when
appropriate as well as utilize the RN for all clinical issues
pertaining to the IW's claims. Identify IWs who are potential
vocational rehabilitation candidates and complete the referral
- Adherence to all Health Management Solutions (HMS) policies and
URAC standards as well as all Confidentiality policies and
guidelines. Ensure that all documentation is current, accurate, and
complete including remaining current with all diaries. Follow all
HMS and BWS guidelines for appropriate medical management of claims
and participate in educational and informational seminars as
- Completion of team peer-to-peer FROI/CE audits
- Other duties as assigned.
- High School/GED Certificate
- 2 years managed care experience preferred
- Exceptional written, telephonic, and oral communication (public
speaking), leadership, problem-solving, interpersonal, and
organizational skills required. Ability to coordinate and organize
- Excellent knowledge of medical terminology
- Experience using Microsoft Office programs, especially Excel,
Word, PowerPoint, and Access.
ProMedica is a mission-based, not-for-profit integrated healthcare
organizational headquartered in Toledo, Ohio. - -For more
information, please visit -www.promedica.org/about-promedica
Qualified applicants will receive consideration for employment
-without regard to race, color, national origin, ancestry,
religion, -sex/gender (including pregnancy), -sexual orientation,
gender identity or gender expression, age, physical or mental
disability, military or protected veteran status, citizenship,
familial or marital status, genetics, or any other legally
protected category. In compliance with the Americans with
Disabilities Act Amendment Act (ADAAA), if you have a disability
and would like to request an accommodation in order to apply for a
job with ProMedica, please contact -email@example.com
Equal Opportunity Employer/Drug-Free Workplace
Keywords: ProMedica, Lorain , FROI / Claims Examiner - Paramount, Other , Lorain, Ohio
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