Workers Compensation Claims Auditor

ATHENS POSITION DETAILS

Position Title

Workers’ Compensation Claims Auditor

Department

Claims & Operations Compliance

Reports To

Audit and Compliance Supervisor

FLSA Status

Non-Exempt

Job Grade

12

ATHENS ADMINISTRATORS

Explore the Athens Administrators difference: We have been dynamic, innovative leaders in claims administration since our founding in 1976. We foster an environment where employees not only thrive but consistently recognize Athens as a “Best Place to Work.” Immerse yourself in our engaging, supportive, and inclusive culture, offering opportunities for continuous professional growth. Join our nationwide family-owned company in Workers' Compensation, Property & Casualty, Program Business, and Managed Care. Embrace a change and come make an impact with the Athens Administrators family today!

Position Summary

Athens Administrators has an immediate need for a Workers’ Compensation Claims Auditor to support our Workers’ Compensation department and can be located anywhere in the state of California, however, employees who live less than 26 miles from the Concord, CA or Orange, CA offices are required to work once a week in the office on a day determined by their supervisor between Tuesday – Thursday. The remaining days can be worked remotely if technical requirements are met, and the employee resides in California. Athens offices are open for business Monday-Friday from 7:30 a.m. to 5:30 p.m. local time. The schedule for this position is Monday-Friday at 37.5 hours a week.

The primary responsibility of the Workers’ Compensation Claims Auditor is to assist in ensuring that the handling of workers’ compensation claims meets both internal and customer-level quality expectations. This position involves coordinating the analysis and review of insurance claims for accuracy. This is typically accomplished by performing routine and focused audits of all aspects of the claims process, with an emphasis on quality of claim management and resolution strategy. The WC Claims Auditor may help to resolve or reconcile any discrepancies found within the claims that they review and support the activities of the claims department.

The WC Auditor will analyze data to identify trends that are contributing to positive outcomes as well as areas of opportunity. They will coordinate and create training materials to address the trends in claims handling. Individual findings and recommendations will be provided to the Audit & Compliance Supervisor for review and distribution to the claims staff. The WC Auditor will be responsible for maintaining records for all claims that they process or review. Additionally, they will run and analyze reports in order to effectively manage the audit process and will track and document audit findings. This individual will seek to determine the origin(s) of any deficiencies and will work with the Audit & Compliance Supervisor and Claims Management to assist with appropriate resolution. This position will assist with the review and coordination of responses to requests for information and data from carriers, clients, and external auditors.

Primary Responsibilities

Our new hire should have the skills, ability, and judgment to perform the following essential job duties and responsibilities with or without reasonable accommodation. Additional duties may be assigned:

• Audit claim files for compliance with client service instructions, Athens’ Best Practices, and State and Federal regulations
• Work with WC leadership, Corporate Trainers, and additional strategic business partners and vendors to ensure adherence to programs
• Ensure compliance with SCHIP coding
• Preparation of training for technical staff as needed
• Act as a technical resource for the claims staff and provide technical assistance on special projects
• Make recommendations for claims processing improvement efforts
• Coordinate with external claim auditors to ensure their pre-audit needs are met.
• Conduct regulatory audits and provide feedback to compliance management on measures to enhance the auditing process.
• Complete daily, weekly, and monthly audits and share results with the direct line of claims management team
• Provide audit results and work to improve results and enhance the process
• Run reports, prepare spreadsheets and presentations
• Assist with special projects assigned to assist the organization in solving compliance problems and meeting compliance goals
• Develop and provide statistical data on individual employee errors. Identify error trends for specific training needs for Claims staff. Support Claims Supervisors, Division Managers, and other members of Senior Management
• Utilize established training guides, curriculum, and materials
• Exhibit a thorough understanding of industry standard claims processing guidelines
  

Essential Position Requirements

The requirements listed below are representative of the knowledge, skill, and/or ability required. While it does not encompass all job requirements, it is meant to give you a solid understanding of expectations.

• High School Diploma or equivalent (GED) required for all positions
• AA/AS or BA/BS preferred but not required
• 3-5 years’ experience in Workers’ Compensation claims handling
• Experience and proficiency in Data Analysis
• Prior experience with auditing preferred
• Administrators Certificate from Self-Insurance Plans will be required within one year of employment if not already obtained
• Excellent verbal and written communication skills with strong attention to detail, and ability to convey technical details
• Ability to work independently, efficiently, with strong multi-tasking skills.
• Possess independent decision-making skills and demonstrated initiative to resolve issues.
• Ability to thrive in a fast-paced environment
• Must be able to take broad directives and follow through with appropriate action
• Able to develop business relationships with claims colleagues
• Proactive initiative to create efficiencies within a function/process
• Highly computer literate and especially proficient with Microsoft Office applications, including a strong understanding of Excel
• Ability to learn additional computer programs
• Ability to type quickly, accurately and for prolonged periods
• Reasoning ability, including problem-solving and analytical skills, i.e., proven ability to research and analyze facts, identify issues, and make appropriate recommendations and solutions for resolution
• Ability to be trustworthy, dependable, and team-oriented for fellow employees and the organization
• Seeks to include innovative strategies and methods to provide a high level of commitment to service and results
• Ability to demonstrate care and concern for fellow team members and clients in a professional and friendly manner
• Acts with integrity in difficult or challenging situations and is a trustworthy, dependable contributor
• Athens’ operations involve handling confidential, proprietary, and highly sensitive information, such as health records, client financials, and other personal data. Therefore, maintaining honesty and integrity is essential for all roles within the company.
• Must be able to reliably commute to meetings as required by this position
  

APPLY WITH US

We look forward to learning about YOU! If you believe in our core values of honesty and integrity, a commitment to service and results, and a caring family culture, we invite you to apply with us. Please submit your resume and application directly through our website at http://www.athensadmin.com/careers/job-openings Feel free to include a cover letter if you’d like to share any other details. All applications received are reviewed by our in-house Corporate Recruitment team. The Company will consider qualified applicants with arrest or conviction records in accordance with the Los Angeles Fair Chance Ordinance for Employers and the California Fair Chance Act. Applicants can learn more about the Los Angeles County Fair Chance Act, including their rights, by clicking on the following link: https://dcba.lacounty.gov/wp-content/uploads/2024/08/FCOE-Official-Notice-Eng-Final-8.30.2024.pdf.

This description portrays in general terms the type and levels of work performed and is not intended to be all-inclusive or represent specific duties of any one incumbent. The knowledge, skills, and abilities may be acquired through a combination of formal schooling, self-education, prior experience, or on-the-job training.

Athens Administrators is an Equal Opportunity/ Affirmative Action employer. We provide equal employment opportunities to all qualified employees and applicants for employment without regard to race, religion, sex, age, marital status, national origin, sexual orientation, citizenship status, veteran status, disability, or any other legally protected status. We prohibit discrimination in decisions concerning recruitment, hiring, compensation, benefits, training, termination, promotions, or any other condition of employment or career development.

THANK YOU!

We look forward to reviewing your information. We understand that applying for jobs may not be the most enjoyable task, so we genuinely appreciate the time you've dedicated. Don’t forget to check out our website at www.athensadmin.com as well as our LinkedIn, Glassdoor, and Facebook pages!

Athens Administrators is dedicated to fair and equitable compensation for our employees that is both competitive and reflective of the market. The estimated rate of pay can vary depending on skills, knowledge, abilities, location, labor market trends, experience, education including applicable licenses & certifications, etc. Our ranges may be modified at any time. In addition, eligible employees may be considered annually for discretionary salary adjustments and/or incentive payments. We offer a variety of benefit plans including Medical, Vision, Dental, Life and AD&D, Long Term Care, Critical Care, Accidental, Hospital Indemnity, HSA & FSA options, 401k (and Roth), Company-Paid STD & LTD and more! Further information about our comprehensive benefits package may be found on our website at https://www.athensadmin.com/careers/why-work-here