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Claims Management Specialist
2 months ago
Position: Claims Adjuster
Summary: This role reports directly to the Claims Supervisor and may require providing technical support in their absence. The Claims Adjuster is tasked with managing a portfolio of claims, which may include complex cases with unique challenges, in compliance with relevant laws and company policies.
Key Responsibilities- Conduct a three-point contact for all new claims within 24 hours, engaging the claimant, employer, and treating physician to gather essential details regarding the incident and ongoing treatment.
- Maintain thorough documentation of case facts and necessary information to establish compensability, assess the need for disability payments, and manage medical expenses.
- Ensure all indemnity claims have an updated action plan detailing steps towards resolution.
- Collaborate with medical case managers to facilitate early return-to-work opportunities, thereby minimizing extended disability costs.
- Refer cases with suspected fraudulent activity to the Special Investigations Unit.
- Pursue subrogation from liable third parties and manage contributions in cases involving multiple defendants.
- Adhere to all applicable statutes and company guidelines in the handling of claim files.
- Review and approve vocational rehabilitation plans as necessary.
- Establish and adjust monetary reserves for cases in line with authority levels.
- Review medical bills for appropriateness before processing for payment.
- Exhibit professionalism and maintain a courteous demeanor in all interactions.
- Respond to inquiries in a timely manner, ensuring effective communication.
- Possess a solid understanding of the Labor Code as it pertains to workers' compensation claims.
- Manage litigation processes effectively.
- Perform additional duties as assigned by the Supervisor or Manager.
To excel in this position, candidates must demonstrate the ability to fulfill each essential duty satisfactorily. The following qualifications are required:
- Bachelor's degree from an accredited institution, with a minimum of seven years of relevant experience or an equivalent combination of education and experience.
- A high level of expertise in claims handling, including at least five years of experience managing indemnity cases with complex issues.
- Possession of an SIP certificate is preferred.
Active pursuit of the IEA Certificate and Self-Insured Certificate, along with successful completion or active study of the WCCP designation or equivalent qualifications.
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