Workers' Compliance Specialist – CMS

• Ensure company compliance with CMS mandatory insurer reporting requirements under Section 111 of MMSEA
• Manage CMS data elements for workers’ compensation claims
• Verify data points and manage CMS-related inquiries, including conditional payment notices and Medicare Advantage liens
• Research and input Section 111 data elements into WCXP/Compliance fields for quarterly CMS submissions
• Maintain ORM diagnosis and TPOC/settlement details for Medicare-eligible injured workers
• Update CMS compliance claim data elements for ORM termination within jurisdictional statutes of limitations
• Establish and maintain diary tasks to monitor ORM reporting and termination
• Maintain knowledge of statutory rules governing termination of benefits in each jurisdiction
• Coordinate and resolve missing data or errors with claim representatives
• Document Section 111 activity in claim notes
• Monitor and handle CMS correspondence and Medicare Beneficiary inquiries
• Direct payments as appropriate
• Attend business unit, department, and company meetings
• Assist with company projects and participate in insurance-related events, seminars, classes, and conferences

• Bachelor’s degree required, or High School Diploma/GED with a minimum of eight years of experience working in a medical, legal, or insurance environment in lieu of the bachelor’s degree
• Minimum of three years of experience in workers’ compensation claims
• Strong working knowledge of medical terminology, common medical procedures, and treatments
• Extensive knowledge of workers’ compensation processes and procedures
• Strong working knowledge of applicable state laws
• Working knowledge of CMS reporting requirements preferred
• Proficiency in Microsoft Office, including Word and Excel
• Ability to learn new computer software applications
• Attention to detail and ability to establish priorities and meet deadlines
• Ability to handle multiple priorities simultaneously
• Excellent organization and time management skills
• Excellent analytical and problem-solving skills
  
  Ability to assess urgency and importance and take appropriate action
• Ability to communicate effectively and professionally verbally and in writing
• Ability to maintain confidential information
• Ability to operate standard office equipment
• Ability to attend insurance and industry/business functions
• Empathic listening skills and ability to build mutual understanding and trust

Demonstrates expertise in managing CMS compliance and workers' compensation claims, with a strong understanding of medical terminology and applicable state laws. Proficient in data management and reporting, with excellent organizational and analytical skills.

• CMS Compliance Management
• Workers' Compensation Claims Processing
• Medical Terminology Knowledge
• Microsoft Office Proficiency
• Attention to Detail

• CMS Reporting Requirements
• Data Management
• Workers' Compensation Processes
• Statutory Rules Knowledge
• Analytical Skills

• Effective Communication
• Time Management
• Problem-Solving
• Empathic Listening
• Organizational Skills

• Insurance Compliance
• Medicare Advantage Liens
• Conditional Payment Notices
• ORM Reporting
• Jurisdictional Statutes

• WCXP/Compliance Software
• Microsoft Word
• Microsoft Excel