ABOUT US:
Founded in 2022, ForzaCare is a purpose-driven organization that helps injured individuals recover faster and return to work safely through coordinated, clinically appropriate care.
ForzaCare is proud to be part of Ethos Risk Services, a leading national provider of investigative and risk mitigation solutions. Together, we're expanding our reach and strengthening our ability to deliver exceptional service across the workers' compensation industry. Learn more about ForzaCare and Ethos partnership here.
JOB SUMMARY:
Our medical management team is growing and seeking a full-time Medical Set-Aside & Medical Cost Projection Specialist to coordinate and support MSP compliance services, including MSAs, Conditional Payments, Life Care Plans, and Medical Cost Projections. This role manages cases from intake through completion, ensuring deliverables are accurate, compliant with CMS guidelines, and serve as a key resource for internal teams and external clients. This position is predominantly remote, with limited travel required on an as-needed basis.
KEY RESPONSIBILITIES:
Operational Oversight & Workflow Management
- Manage workflow from intake through completion, ensuring timelines and service standards are met.
- Review and process new referrals, confirming all required documentation is obtained.
- Track case progress, monitor pending items, and follow up to ensure timely resolution.
- Maintain accurate internal logs, tracking systems, and status updates.
Medicare Compliance & Administration
- Ensure all work aligns with CMS guidelines and Medicare Secondary Payer (MSP) regulations.
- Utilize CMS systems (e.g., WCMSA, MSPRP) to support case processing and submissions.
- Review and respond to CMS correspondence, including approvals and development requests.
- Assist with Medicare entitlement verification, including coordination with the BCRC.
MSA, Conditional Payments & Cost Projection Services
- Review and organize medical records to assess treatment history and future care needs.
- Support preparation of Medicare Set-Asides (MSAs), Conditional Payment investigations, and cost projections.
- Assist in estimating future medical costs based on documentation and established guidelines.
- Ensure all deliverables meet compliance standards and are defensible.
Quality Assurance & Documentation
- Perform quality checks on reports, submissions, and supporting documentation.
- Ensure accuracy, consistency, and completeness across all case deliverables.
Client & Internal Collaboration
- Communicate with clients regarding case status, documentation needs, and timelines.
- Collaborate with internal teams across operations and clinical resources.
QUALIFICATIONS:
Education / Licensure / Certifications
- Active Registered Nurse license OR Certified Rehabilitation Counselor (CRC) license with associated college degree OR CCM certification (required).
- Certified Medicare Secondary Payer (CMSP) certification (strongly preferred).
- Other certifications such as MSCC, MSA-C, CLCP, CNLP or CDMS (preferred).
- Valid driver's license, reliable transportation, and auto insurance (required).
Experience / Skills
- Experience in Medicare compliance, submissions, and appeals (required).
- Basic knowledge of medical terminology, diagnosis, and procedure familiarity (required).
- Background in workers' compensation, medical case management, or cost containment (preferred).
WORKING CONDITIONS:
This position is primarily remote, with occasional travel that may be required. The role involves prolonged periods in a stationary position and continuous use of a computer and standard office equipment. Regular communication via phone, video, and written correspondence with clients, customers, and team members is required.
ForzaCare and Ethos Risk Services is an equal opportunity employer that does not discriminate on the basis of religious creed, sex, national origin, race, veteran status, disability, age, marital status, color or sexual orientation or any other characteristic.