PRIMARY PURPOSE:

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.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

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.

ADDITIONAL FUNCTIONS and RESPONSIBILITIES

Performs other duties as assigned.

Supports the organization's quality program(s).

Travels as required.

QUALIFICATIONS

Education & Licensing

Bachelor's degree from an accredited college or university preferred.

Experience

Four (4) years of claims management experience or equivalent combination of education and experience required.

Skills & Knowledge

Working knowledge of regulations, offsets and deductions, disability duration, medical management practices and Social Security and Medicare application procedure 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 skill

Good interpersonal skills

Excellent negotiation skills

Ability to work in a team environment

Ability to meet or exceed Service Expectations

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