Workers Compensation Medical Claims Specialist

1 day ago

Charleston, West Virginia, United States PEOPLEASE Full time
Position Summary

The PEOPL EASE Group (TPG) is a leading Professional Employer Organization (PEO) serving 70,000 employees. TPG's industry focus and strategic growth plan have positioned us to be the leading provider of PEO services in the United States serving the blue and gray collar markets.

We are seeking a skilled Workers Compensation Medical Only Claims Analyst to join our team. This dynamic position is part of our workers' compensation claims team and will be responsible for claims investigation, claim reporting, and timely, effective claim management of workers' compensation medical only claims.

This role works collaboratively with our clients, insurance carriers, and loss control personnel to effectively reduce and mitigate our workers' compensation exposures. The ideal candidate will have the ability to manage and execute the coordination of multiple projects within required timeframes and expectations; demonstrated excellence in communication skills; be able to inform both orally and in writing; working knowledge of Microsoft Office products.

The successful candidate will be a self-starter with the ability to function as a remote employee in a distributed work team. They will be responsible for investigating new employee injuries, checking policy coverage, determining subrogation potential, and ensuring injured workers receive initial medical treatment.

The Workers Compensation Medical Only Claims Analyst will also be responsible for coordinating light duty availability, maintaining communication with insurance adjusters and clients, monitoring medical treatment, and maintaining organized files. They will work closely with our underwriters and other internal departments to coordinate and deliver our products and services to our clients.

Essential Duties and Responsibilities

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Investigate new employee injuries by contacting our client, the injured worker, his/her supervisor, or witnesses and reviewing all evidence received related to the work incident.
  • Check policy coverage to ensure new claims received are covered, set up to the correct location and reported to the appropriate insurance carrier.
  • Determine whether there is any possible subrogation potential on a new claim.
  • Ensure the injured worker has been offered and/or received initial medical treatment if needed.
  • Coordinate light duty availability with our client employer so that the injured worker can return to work within the waiting period when possible.
  • Maintain communication with the insurance adjuster, Client and injured worker, and any other persons involved throughout the claim so that everyone is aware of current updates.
  • Monitor medical treatment and ensure the injured worker is attending scheduled appointments and continues to work.
  • Maintain an organized file, documented with clear and concise notes of activities, medical treatment, return to work status and action plan to allow for easy review of the file by co-workers or managers.
  • Maintain and document an accurate return to work history on each claim for OSHA log reporting and compliance.
  • Maintain a diary with tasks assigned for each claim so that all claim files are monitored, reviewed, and closed on a timely basis.
  • Determine when vendor involvement may be necessary, such as medical case management, vocational rehabilitation counseling, legal, surveillance, Independent Medical Examiner (IME), Independent Adjuster (IA), etc., and discuss with Claims Manager.
  • Ability to oversee Insurance Carrier or Third-Party Administrator (TPA) staff to ensure best practices and contractual compliance. Ensure our partners control the cost of claims through effective diary management and oversight of claim files.
  • Ensure the medical records and bills are received by CCMSI and push for a claim closure.
  • Provide exceptional client service to internal and external Clients.
Minimum Qualifications (Knowledge, Skills, and Abilities)
  • Bachelor's degree in Risk Management, Insurance or related field, or equivalent combination of experience and education
  • Minimum of 1+ years' claims experience or employer risk management experience.
  • Strong analytical and problem-solving skills and sound judgment
  • Ability to work independently and multi-task
  • Effective communication skills, written and verbal
  • Exceptional client service skills
  • Excellent problem-solving, interpersonal, and organizational skills
  • Strong computer skills in Microsoft Office products
Physical Demands and Work Environment

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the functions. While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands or fingers, handle or feel objects, tools, or controls. The employee is occasionally required to stand; walk; sit; and reach with hands and arms. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this position include close vision, distance vision, and the ability to adjust focus. This position will be working primarily indoors and some of the time in an outdoor environment. From this movement, the employee will encounter varying temperatures. The normal auto and air travel hazards will apply.

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