Job Description
Job Description
Description :
To analyze mid- and higher-level workers compensation claims to determine benefits due; to ensure ongoing adjudication of claims within company standards and industry best practices;
and to identify subrogation of claims and negotiate settlements.
Manages workers compensation claims determining compensability and benefits due on long term indemnity claims, monitors reserve accuracy, and files necessary documentation with state agency.
Develops and manages workers compensation claims' action plans to resolution, coordinates return-to-work efforts and approves claim payments.
Approves and processes assigned claims, determines benefits due, and manages action plan pursuant to the claim or client contract.
Manages subrogation of claims and negotiates settlements.
Communicates claim action with claimant and client.
Ensures claim files are properly documented, and claims coding is correct.
May process complex lifetime medical and / or defined period medical claims which include state and physician filings and decisions on appropriate treatments recommended by utilization review.
Maintains professional client relationships.
Supports the organization's quality program(s).
Travels as required.
QUALIFICATIONS
Bachelor's degree from an accredited college or university preferred.
SIP is preferred not mandatory.
Min 3 Years of CA claims handling experience required.
4 years of claims management experience or equivalent combination of education and experience required.
Subject matter expert of appropriate insurance principles and laws for line-of-business handled, recoveries offsets and deductions, claim and disability duration, cost containment principles including medical management practices and Social Security and Medicare application procedures as applicable to line-of-business.
Excellent oral and written communication, including presentation skills
PC literate, including Microsoft Office products
Analytical and interpretive skills
Strong organizational skills
Good interpersonal skills
Excellent negotiation skills
Ability to work in a team environment
Ability to meet or exceed Service Expectations
Mental : Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion;
ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines
Remote in CA preferred. If candidate is from other state, 3 years of CA Claims handling experience is must.
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