Job Summary: The Claim Review Specialist II is responsible for processing and managing workers’ compensation claims by gathering required information, documenting claim details, and communicating with employers, providers, injured workers, and the Bureau of Workers’ Compensation. This role ensures accurate claim entry, collects necessary medical documentation, and supports proactive claims management, including early return-to-work initiatives. The specialist also provides excellent customer service to internal and external partners while maintaining quality, productivity, and compliance standards.

Principal Duties & Responsibilities:

• Reports directly to the Claim Review Specialist Team Leader
• Enter and process initial claims in system, complete initial and/or follow-up calls to employer, provider, IW, and BWC as appropriate while documenting the results of gathered information. Additionally, responsible for complete follow-up on claims, resulting in transition to the Return-to-Work Specialist or case closure as appropriate, including gathering any additional information on RTW, missing claims master fields, continued treatment, etc
• Gather complete information on all mandatory system field requirements to ensure accurate transmission to the BWC
• Gather all initial and subsequent medical documentation necessary to process potential claim updates
• Assist in identifying RAW and Onsite Therapy candidates where appropriate
• Proactive claims management, early RTW intervention, and transfer of claims to Return to Work Specialist for continued RTW management when appropriate or to Case Management
• Assists other Claim Review Specialists on the team
• Answering incoming and making outgoing phone calls
• Provide excellent customer service to all internal and external customers
• Required to meet team quality and productivity standards
• Maintain and develop teamwork within all departments of UniComp
• Complete audit findings timely
• Respond to external and internal e-mails within 1 business day of receipt unless otherwise specified
• Other duties as assigned by Management
• Maintain and exhibit Sheakley Core Values

Qualifications:

• Knowledge and skills at a level normally acquired through the completion of High School education or equivalent
• Ability to handle sensitive information and maintain a high level of confidentiality
• Proficiency in Microsoft Office products including Word, Excel, Outlook, etc
• Medical Terminology or equivalent experience
• Previous customer service experience

Requirements:

• Attention to detail, flexibility, and strong ability to multi-task
• Problem solving ability

Physical and Mental Demands:

• Ability to sit for prolonged period
• Ability to answer high call volume while maintaining accurate system notes

This job description is not intended to be all inclusive and the employee will also perform other reasonably related business duties as assigned by the immediate supervisor and other management as required.