• Manages a high frequency desk, which includes primarily medical only claims. • Responsible for the investigation, evaluation, and determination of compensability for work-related injury and disease claims following established guidelines to determine benefit eligibility. • Provides superior service in a cost-effective manner to achieve best possible outcomes and proactively collaborate across the enterprise to ensure alignment of objectives and foster continuous improvement. • Gathers relevant facts by performing three-point contacts with involved parties and completing a thorough claim investigation prior to issuing a compensability determination. • Decides the outcome of claims using sound judgment and applying established policy, procedures, regulations, and guidelines. • Evaluates and establishes an action plan to manage benefits associated with primarily medical only and occupational disease claims to their most cost-effective conclusion. • Determines eligibility of benefits once medical treatment plans have been secured and processed within the designated authority levels. • Actively identifies and develops the investigation of and pursuit of subrogation recoveries when possible. • Utilizes proactive reserving behaviors to ensure adequate case reserves which reflect the probable ultimate outcome based on the current known circumstances throughout the life of the claim. • Consults with lost time claims specialists and/or complex claims specialists, director or Claims Product and Operations staff, as needed. • Analyzes reports from external resources such as physicians, attorneys, and/or vocational rehabilitation experts to evaluate and adjust claim strategies as needed. • Evaluates and negotiates claim settlements utilizing human relation skills and technical knowledge to achieve the best possible outcome. • Effectively and independently uses available resources to prioritize, organize, and complete work in a timely manner to meet jurisdictional requirements, timeframes, and internal metrics. • Follows established claims best practices related to medical management, litigation, fraud/abuse and recovery. • Works collaboratively with the injured worker, employer, outside counsel, and health and rehabilitation professionals to manage the claims costs and promote quality medical care. • Along with the claim director, regional vice president and other claims staff, participates in claim reviews, onboardings, etc. for our policyholders and agents. • Proactively collaborates with our policyholders to ensure alignment of objectives and foster continuous improvement.

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description Lumicera Health Services is seeking a Reimbursement Specialist Team Lead to join our team! Under direction from the Supervisor or Assoc. Manager, Specialty Pharmacy Services and pharmacists in the Specialty Pharmacy, the Reimbursement Specialist Team Lead is primarily responsible for following standard operating procedures to monitor, review and investigate claim submissions and responses. Additionally, the Reimbursement Team Lead will provide guidance and corrective action to applicable pharmacy staff. The Reimbursement Specialist Team Lead shall have knowledge of billing procedures and work to reduce discrepancies, inaccuracy, and outstanding balances. This individual may be assigned to additional projects and responsibilities outside of regular pharmacy duties and will help to mentor and train new and existing Lumicera employees. This position may function with and assist any other area in the facility as needed. Responsibilities - Responsible for ongoing monitoring of claims activity for accuracy and successful submission - Responsible for ensuring that patient billing information is set up appropriately in the pharmacy software - Responsible for understanding the nuances of copay programs, copay cards, and how that relates to Lumicera patient copay structures - Responds to employee/patient/client questions or complaints regarding reimbursement and/or billing - Works with internal teams to review and resolve claim issues - Responsible for managing failed claims in a timely fashion - Maintains accurate reference information relating to reimbursement and copay assistance - Assists in mentoring and training new and existing Lumicera employees to maintain the Lumicera service model - Other duties as assigned Qualifications - High school diploma or GED. Some college preferred - CPhT Preferred - Pharmacy technician license or pharmacy technician trainee license is strongly preferred in states requiring pharmacy technician licensure - Experience with pharmacy, health plan or clinical insurance claims billing, benefit assessments, billing/claims documentation, or claims auditing is preferred - Preferred understanding of Specialty Pharmacy drugs including REMS and Limited Distribution Products best practices - At least 2 years’ experience and demonstration of proficiency in position at Lumicera or equivalent preferred - Must have schedule flexibility and be able to work overtime to support company needs - Participate in, adhere to, and support compliance program objectives - The ability to consistently interact cooperatively and respectfully with other employees Benefits - Top of the industry benefits for Health, Dental, and Vision insurance - 20 days paid time off - 4 weeks paid parental leave - 9 paid holidays - 401K company match of up to 5% - No vesting requirement - Adoption Assistance Program - Flexible Spending Account - Educational Assistance Plan and Professional Membership assistance - Referral Bonus Program – up to $750!

• To analyze complex errors and omissions, directors and officers claims • To provide resolution of highly complex nature and/or severe injury claims • To coordinate case management within Company standards, industry best practices and specific client service requirements • To manage the total claim costs while providing high levels of customer service • Conducts or assigns full investigation and provides report of investigation pertaining to new events, claims and legal actions. • Negotiates claim settlement up to designated authority level. • Calculates and assigns timely and appropriate reserves to claims; monitors reserve adequacy throughout claim life. • Recommends settlement strategies; brings structured settlement proposals as necessary to maximize settlement. • Coordinates legal defense by assigning attorney, coordinating support for investigation, and reviewing attorney invoices; monitors counsel for compliance with client guidelines. • Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall claim cost for our clients. • Identifies and investigates for possible fraud, subrogation, contribution, recovery, and case management opportunities to reduce total claim cost. • Represents Company in depositions, mediations, and trial monitoring as needed. • Communicates claim activity and processing with the client; maintains professional client relationships. • Ensures claim files are properly documented and claims coding is correct. • Refers cases as appropriate to supervisor and management. • Delegates work and mentors assigned staff.

• To analyze complex or technically difficult general liability claims to determine benefits due; • To work with high exposure claims involving litigation and rehabilitation; • To ensure ongoing adjudication of claims within service expectations, industry best practices and specific client service requirements; • To identify subrogation of claims and negotiate settlements. • Analyzes and processes complex or technically difficult general liability claims by investigating and gathering information to determine the exposure on the claim; • Manages claims through well-developed action plans to an appropriate and timely resolution. • Assesses liability and resolves claims within evaluation. • Negotiates settlement of claims within designated authority.