Claims Compliance Lead - Work Comp

Job Title:

Claims Compliance Lead FLSA Status:

Exempt Job Family:

Claims Department:

Work Comp Claims Location:

Corporate Office (Fort Wayne, IN)

JOB SUMMARY

Oversees the daily implementation of applicable compliance, regulatory, technological, and internal/external subject matter expert functions on behalf of the Workers' Compensation Claims Department. Responsible for all Medicare compliance applicable to workers' compensation claims. Responsible for implementation, testing, and oversight of electronic data interchange and compliance with same, jurisdictional audits, data calls, and annual reports, review and processing of jurisdictional penalties, initial point of contact and internal lead on all

USR & IDC

department needs and will serve as the initial point of contact and liaison between WC Claims, IT, Compliance, and

R&D. POSITION ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Monitoring and interpreting state and federal regulations governing Workers' Compensation claims. This includes ensuring that procedures comply with applicable laws and regulatory requirements. Leading the selection, implementation, and optimization of technology solutions for workers' compensation, including claims management software (ClaimCenter), data analytics tools, AIdriven platforms, and workers' compensation software system accelerators/integrations. Assuring full compliance with Medicare/CMS Section 111 Reporting, MSA data collection and requirements, MSA settlement requirements, data sharing with Medicare/CMS in general as well as training and compliance with all Medicare requirements secondary to workers' compensation claims. Ensure consistency with the workers' compensation claims handling, regulatory requirements and reporting systems. Analyzing claims data to identify trends, compliance issues, and opportunities for improvement. Preparing reports for management, highlighting compliance status and recommending solutions. Collaborating with internal departments (IT, Compliance, Legal, HR, Underwriting, etc.) and external stakeholders (regulatory agencies, third-party administrators, etc.) on compliance and technology initiatives. Identifying and evaluating potential risks related to workers' compensation claims and compliance and developing strategies to mitigate these risks. Complete other projects as assigned.

KNOWLEDGE, SKILLS, AND ABILITIES

The requirements listed below are representative of the knowledge, skills, and/or abilities required to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Excellent knowledge of insurance policies and workers' compensation claims philosophy, theory, practice of the WC claim function, procedures, and terminology. Excellent knowledge of WC claims data reporting. Excellent in research, analytics, investigations and problem-solving. Strong knowledge of medical terminology. Excellent computer skills of applicable software and claims systems including Microsoft Office Suite. Superior communication and interpersonal skills. Superior organizational and written communication skills. Ability to work effectively in a team as well as independently. Ability to manage multiple priorities and changing deadlines. Excellent leadership qualities.

Occasional travel:

a valid driver's license with an acceptable motor vehicle report per company standards required if driving. Effectively interface with external contacts, Brotherhood employees, managers, and department staff members.

EDUCATION AND/OR EXPERIENCE

List Degree Requirement, Years' Experience, and Certifications Bachelor's degree, preferably in insurance, finance, accounting, business administration or related field or equivalent relevant experience is required. Five or more years of experience in claims, including experience in workers' compensation claims adjusting & workers' compensation claims compliance or related experience is required. Prior training experience preferred. Insurance industry certifications, such as AIC preferred. Medicare certification strongly preferred. Guidewire testing, implementation, and usage experience preferred. Experience in project management is strongly preferred. Terms and Conditions This description is intended to describe the general content of and requirements for the performance of this position. It is not to be construed as an exhaustive statement of duties, responsibilities, or requirements. Because the company's niche is the church and related ministries market, and because effective service requires a thorough understanding of this market, persons in this position must be familiar with church operations and must conduct themselves in a manner that will neither alienate nor offend persons within this target niche. Brotherhood Mutual Insurance Company reserves the right to modify, interpret, or apply this position description in any way the company desires. This job description in no way implies that these are the only duties, including essential duties, to be performed by the employee occupying this position. This position description is not an employment contract, implied or otherwise. The employment relationship remains "at-will".