Occupational Health Service Representative (Worker's Comp)

Under indirect supervision, maintains patient/employer relationships as related to industrial/occupational, workers compensation and no-fault inquiries; compiles and reports department statistics; communicates, monitors, and processes insurance claims, reports and billing of patients and members being compensated for medical disability benefits; educates parties regarding industrial procedures; coordinates and processes M.D. monthly schedules; schedules and registers industrial and no-fault patients, Occupational Health Services, PEs and drug screen patients; provides patient attending services as required; performs clerical functions as needed; supports compliance and Principles of Responsibility; maintains confidentiality; protects organizational assets; exhibits ethics and integrity; adheres to applicable federal and state laws and regulations, accreditation and licensing requirements, policies and procedures; reports and/or resolves issues of non-compliance.

• Obtains and provides to patient or employer by telephone or personal contact any industrial/occupational medical information, advice or explanation of problems pertaining to benefits, applications, status, eligibility, form filing and time limits; refers difficult or involved problems to supervisor or other appropriate individual.


• Communicates with and provides functional industrial data and information to variety of Kaiser personnel in other departments (e.g., Diagnostic Imaging, outlying clinics, Industrial Insurance, and Risk Management) by telephone, written material or in person; ensures proper handling and completion of claim requests.


• Assists and participates in new patient/employee orientation; verifies patient benefits per Kaiser Health Plan; interprets rules and regulations of health plan, workers compensation, and no-fault as applicable to specific case.


• Receives, reviews, and triages requests for medical information, visit records, insurance billing forms, and other pertinent documents for completeness and accuracy; ensures efficiency in processing of claims; creates requests; maintains industrial/occupational clinic documentation for encounter cases; creates/obtains unit medical charts, industrial medical charts and all other data pertaining to request.


• Facilitates referral process; coordinates prior approvals from insurance carriers; tracks or performs follow-up on approval requests; coordinates appointments within and outside Kaiser; ensures completion and receipt of appropriate documentation required; completes data entry requirements.


• Maintains current departmental files; operates standard office equipment.


• Receives telephone calls and correspondence; handles inquiries and complaints pertaining to patient care issues; refers to supervisor as needed.


• Inputs and updates SIM on all OHS, workers compensation, no-fault, pre and post encounter patient information daily.


• Prepares monthly physician calendar/appointment schedule; coordinates physician activities (e.g. meetings and depositions) as needed; adjusts monthly calendar/appointment schedule as needed.


• Communicates and corresponds with insurance carriers, employers, doctors, patients, attorneys and others; obtains and exchanges complete and valid information regarding patient workers compensations injury claims; ensures proper handling and completion of claims/requests.


• Answers follow up inquiries from third party payers and/or patients; documents inquiries in patient medical and industrial charts.


• Audits pertinent data from patient medical records, visit records, nurse/doctor note and various fee schedules/documents to process insurance claims and reports in compliance with state and federal regulation, laws, guidelines and Kaiser Health Plan policies; prepares billing and invoices referring to fee schedule.


• Maintains familiarity with state, federal, city and county and community agencies; ensures proper and adequate exchange of data and information; ensures proper handling and completion of claims/requests.


• Handles inquiries and complaints pertaining to patient visits; provides ongoing assistance and information to claimant, insurance carrier, attorneys and providers; ensures patient confidentiality according to current federal/state laws and Kaiser Permanente corporate policy.


• Contacts various departments to reconcile discrepancies; maintains control logs; ensures correct computer data processing; researches, analyzes, and modifies errors.


• Provides accurate data; prepares for daily, weekly and monthly departmental revenue statistics.


• Gathers, reviews, and corrects source documents and reports from Industrial-Occupational Medicine department related to utilization data; coordinates and maintains industrial visit encounter forms, industrial insurance forms, physician/nurse reports and data for internal tracking system of current status.


• Implements direct patient education activities/strategies in appropriate content areas.


• Facilitates employee education of department clinical operation and procedures.


• Serves as resource to peers, colleagues, and community; shares clinical experience, education expertise and appropriate patient teaching materials in clinical setting; educates employers and patients regarding policies of WC-1/WC-2/WC-5, and no-fault claims.


• Registers on appropriate documents each industrial and no-fault patient requesting medical service, workslip, refill and supplies; obtains routine personal medical information from patient.


• Requests triage by Industrial RN when necessary; witnesses signed consents by patient.


• Prepares and enters patient, EDS and case management information in SIM system; creates and assists in standardization of SIM computer system forms, format, and data collection.


• Demonstrates knowledge, skills, and abilities necessary to provide culturally sensitive care and/or service.


• Performs other duties and accepts responsibility as assigned.