Senior Workers Compensation Claims Specialist
Property & Casualty Insurance Industry
The perfect applicant will evaluate claims data and carry out inquiries into both routine and moderately complex claims to ascertain coverage, compensability, subrogation, and benefits with moderate supervision. They will adjust and oversee claims within their assigned authority limits. A strong familiarity with California Compensation statute claims is essential. This role encompasses both lost time and complex medical-only assignments. The candidate will verify and assess the validity of coverage. They will initiate contact within 24 hours with the employer and employee, and reach out to the attending physician within 48 hours. In close collaboration with supervision, they will manage catastrophic claims. The applicant is required to conduct phone investigations as outlined in the company's claims handling manual and protocols. They will evaluate and adjust claims while adhering to their authority limits. They will consult with the Claim Manager on claims that require additional support and guidance. When necessary, they will assign cases to nurse case management, keeping an eye on billing and performance. The candidate will set reserves for anticipated liabilities, keeping within authority limits, and will complete the obligatory Reserve Worksheets. They will establish reserves that involve complex analysis, including lifetime pharmacy and cost inflation. Coordination of return to work (RTW) will also be part of this role, along with setting target dates. The applicant will maintain diaries at a maximum interval of three months. They will document the claims system files and review medical bills for causal relationships, assess the appropriateness of medical bill charges, and authorize payments. Adherence to special account handling (SHI) guidelines is crucial. They will also participate in account meetings both by phone and in-person. The candidate will oversee litigation related to their files.
A college degree, preferably a B. A., or equivalent experience is required. The applicant should have a minimum of three years of experience (five preferred) in managing California workers' compensation claims. Skills in foreign language communication are an added benefit. The candidate must reside in CA, OR, WA, or ID and this position can be fully remote.