Workers Compensation Claims Specialist

8 hours ago

Fresno, California, United States Intercare Insurance Full time
Job Summary

As a Workers Compensation Adjuster III at Intercare Insurance, you will play a critical role in managing an assigned inventory of claim files, including cases of extreme complexity or with unique or unusual issues. Your primary responsibility will be to effectively manage claims to conclusion, ensuring compliance with applicable statutes and company rules.

Key Responsibilities
  • Perform a three-point contact on all new losses within 24 hours to document relevant facts and establish compensability.
  • Accurately document ongoing case facts and relevant information necessary for establishing compensability and resolving the claim.
  • Develop and maintain up-to-date plans of action for assigned indemnity claims to ensure timely resolution.
  • Collaborate with medical case managers to maximize early return to work potential and reduce extended disability payments.
  • 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, service contracts, and company guidelines.
  • Review and approve vocational rehabilitation plans.
  • Establish, monitor, and adjust monetary case reserves as necessary.
  • Review medical bills for appropriateness prior to referral for payment.
  • Exhibit a courteous and helpful attitude, projecting 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 succeed in this role, you should possess the following competencies:

  • Problem Solving - Identifies and resolves problems in a timely manner, gathering and analyzing information skillfully.
  • Customer Service - Manages difficult customer situations, responds promptly to customer needs, and meets commitments.
  • Interpersonal - Focuses on solving conflict, maintains confidentiality, and remains open to others' ideas.
  • Team Work - Supports everyone's efforts to succeed.

Qualification Requirements:

To perform this job successfully, you must have a Bachelor's degree and at least seven years of related experience, or an equivalent combination of education and experience. A high degree of claims handling expertise is required, including a minimum of five years of experience managing indemnity cases with complex or high potential subrogation, rehabilitation, medical management, and/or legal issues.

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