Workers Compensation Claims Specialist

2 days ago

Orange, California, United States Intercare Insurance Full time
Job Description

Job Summary:

As a Workers Compensation Claims Specialist at Intercare Insurance, you will be responsible for managing an assigned inventory of claim files, including cases of extreme complexity or with unique issues. You will work closely with the Claims Supervisor and medical case manager to maximize early return to work potential and reduce the need for extended disability payments.

Key Responsibilities:

  • Perform a three-point contact on all new losses within 24 hours to document relevant facts and disability status.
  • Thoroughly document ongoing case facts and relevant information for establishing compensability and resolving the claim.
  • Develop and maintain up-to-date plans of action for assigned indemnity claims.
  • Partner with the medical case manager to maximize early return to work potential.
  • Initiate referrals to the Special Investigations Unit (SIU) for cases with suspected fraud.
  • Pursue subrogation from culpable third parties and contributions on multiple defendant cases.
  • Ensure claim files are handled in accordance with applicable statutes and company guidelines.
  • Review and approve vocational rehabilitation plans.
  • Establish and adjust monetary case reserves as needed.
  • Review medical bills for appropriateness prior to referral to InterMed for payment.
  • Exhibit a courteous and helpful attitude and project a professional image on behalf of the company.
  • Respond to telephone messages and inquiries within 24 hours and written inquiries within one week.

Requirements:

To perform this job successfully, you should demonstrate the following competencies:

  • Problem Solving - Identify and resolve problems in a timely manner, gather and analyze information skillfully, develop alternative solutions, and use reason even when dealing with emotional topics.
  • Customer Service - Manage difficult or emotional customer situations, respond promptly to customer needs, respond to requests for service and assistance, and meet commitments.
  • Interpersonal - Focus on solving conflict, not blaming, maintain confidentiality, listen to others without interrupting, keep emotions under control, and remain open to others' ideas and try new things.
  • Team Work - Support everyone's efforts to succeed.

Qualification Requirements:

To perform this job successfully, you must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience:

Bachelor's degree (B.A.) from a four-year college or university, at least seven years related experience and/or training, or an equivalent combination of education and experience. Requires a high degree of claims handling expertise, including a minimum of five years experience managing indemnity cases, many with complex or high potential subrogation, rehabilitation, medical management, and/or legal issues, and possess an SIP certificate.

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