Claims Service Specialist

3 weeks ago

Itasca, United States Captive Resources Full time

The Claims Service Specialist will support the Claims Services Managers (CSM's) to help ensure member claim service satisfaction and provide claims service management ensuring proper communication and follow through

ESSENTIAL EDUCATION AND EXPERIENCE:

Bachelor's Degree or equivalency in a related discipline and at least five (5) years of experience in workers' compensation claims handling (California experience a plus) and claims customer service. Must have direct client service experience in commercial claims either through face-to-face or telephonic experience.

SKILLS/COMPETENCIES REQUIREMENTS:

  • Strong customer service orientation
  • Organization, planning, and prioritization expertise with strong skills in multi-tasking and follow-up
  • Works well independently and in a team environment
  • Excellent written and verbal communication skills
  • Comfortable in a client facing role
  • Strong analytical, problem solving, judgment, and communication skills
  • Willingness and ability to travel domestically at a minimal amount as required
ESSENTIAL DUTIES AND RESPONSIBILITIES:
  • Act as a liaison between the member, broker and the claims administrator on claim and customer service matters.
  • Regularly engage with clients to address questions and opportunities and ensure a transparent and supportive communication channel throughout the claims process.
  • Proactively identify potential issues within claims, working diligently to resolve concerns and prevent escalations.
  • Collaborate with internal and external teams to define and address member needs.
  • Maintain accurate and organized records of activities, outlining ongoing client communication, history of escalations and opportunities. Prepare detailed reports for review and analysis.
  • Coordinate member / broker calls to ensure all claim and captive related questions and concerns are addressed.
  • Closely collaborate with the Claims Services Manager (CSM) and Captive Executive, when necessary to ensure a cohesive response and prioritization of the issue at hand.
  • Actively meet with CSM to provide various updates and deliver a coordinated support of member's needs.
  • Complete periodic claim audits to monitor service levels and compile and review results with CSM.
APPROACH AND DELIVERABLES:
  • Candidate will contact all members in the captive with open claims twice per quarter or as designated by the CSM. More frequent contact may be required per member needs.
  • Maintain record of interaction that documents the "health" of each member.
  • Report out to CSM and CE on monthly basis on any significant claims or claims of interest
  • Meet with the CSM monthly to deliver updates and review more significant matters.
  • Prioritize members via a traffic light methodology and collaborate with the CSM in prioritizing member needs. For those members identified with significant concerns over claims handling, more frequent contacts are necessary.
  • Identify those members with broker claims liasons/examiners and proactively reach out to those contacts periodically to determine if concerns with individual claims. Trends, areas of concern or increasing numbers of issues, should be escalated to CSM.
  • Escalate complex claims matters and highly critical member calls to the CSM.
  • Review claims for flagged members to identify opportunities in customer service and claims handling.
  • Review new claims and open claims that meet criteria to audit claims files for quality and timely handling and ensure progress. Record results for reporting.
  • Reviewing monthly LHA on new claims to identify any significant claims or frequency concerns. Advise CSM and followup with member, if needed.
  • Identify claims with no activity for a period or that are at a point needing to be closed, and following up with the TPA.
  • As required, include the TPA's claim team/account management in review and resolution of significant claim issues.
  • Position will be responsible for logging their work progress, member interactions, specific claim issues and task followup in a TBD system.
  • Foster positive relationships with adjusters, supervisors and their account manager. Work cohesively and positively with broker claims contacts.


PRIORITIES: Proactive claims service management ensuring proper communication and follow through, as well as supporting the CSM as needed to help ensure member claim service satisfaction.

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