Claims Management Specialist
1 week ago
Position: Claims Adjuster
Summary: This role involves direct reporting to the unit Claims Supervisor and may require providing technical support in their absence. The primary responsibility is to effectively manage an assigned inventory of claim files, which may include complex cases or those with unique issues, in accordance with applicable regulations and company policies.
Key Responsibilities- Conduct a thorough three-point contact on all new claims within 24 hours, including communication with the claimant, employer, and treating physician to gather relevant incident details and treatment status.
- Maintain accurate documentation of ongoing case facts and essential information to establish compensability, determine the need for disability payments, and manage medical and expense payments.
- Ensure all assigned indemnity claims have an updated action plan outlining anticipated activities for claim resolution.
- Collaborate with the medical case manager to enhance early return-to-work opportunities, thereby minimizing extended disability payments and associated costs.
- Refer cases with suspected fraud to the Special Investigations Unit (SIU).
- Pursue subrogation from liable third parties and manage contributions in multi-defendant cases.
- Ensure compliance with applicable statutes and company guidelines in handling claim files.
- Review and approve vocational rehabilitation plans as necessary.
- Establish and adjust monetary case reserves in strict accordance with assigned authority levels.
- Review medical bills for appropriateness before processing for payment.
- Exhibit professionalism and maintain a courteous demeanor while representing the company.
- Respond to inquiries promptly, ensuring communication within established timeframes.
- Possess a working knowledge of the Labor Code as it pertains to workers' compensation claims.
- Manage and oversee the litigation process effectively.
- Perform additional duties as assigned by the Supervisor or Manager.
To excel in this position, candidates must demonstrate the ability to perform essential duties satisfactorily. The following qualifications are representative of the knowledge, skills, and abilities required:
Education and ExperienceA Bachelor's degree from an accredited institution, coupled with a minimum of seven years of relevant experience or training, or an equivalent combination of education and experience. A high level of expertise in claims handling is essential, including at least five years of experience managing indemnity cases with complex issues.
Certificates and LicensesActive pursuit of the IEA Certificate and Self-Insured Certificate, along with successful completion or active study for the WCCP designation or equivalent related studies.
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