Description
Responsible for ensuring the proactive management of work-related illnesses and injuries by utilizing an outcome-based disability management model. Exercises significant discretion in the determination of compensability of workers compensation claims. Estimates the costs of personal injury, considering such factors as nature of the injury, diagnosis, prognosis, earning capability, and the need for rehabilitation. Negotiates and settles with claimants and/or attorneys, within authority, at earliest possible point to bring cases to final disposition.
***MUST HAVE EXPERIENCE WORKING WITH ILLINOIS STATE WORKER'S COMPENSATION CLAIMS ***
RESPONSIBILITIES/TASKS:
· Exercises significant discretion in the determination of compensability of workers compensation claims. Estimates the costs of personal injury, considering such factors as nature of injury, diagnosis, prognosis, earning capability, and the need for rehabilitation.
· Proactively utilizes disability management software to assess diagnosis and related disability duration.
· Evaluates work-related disabilities to determine appropriate referral for physician or nurse review. Proactively assists in appropriate return to work.
· Estimates losses required to cover claims and creates monetary reserves accordingly, within authority
· Investigates claims made by claimants for workers compensation injuries including 3-point contacts inclusive of interviewing policyholders, injured workers, agents and providers.
· Obtains all necessary documentation from the appropriate parties within established timelines. Determines and manages necessary follow-up care; e.g., rehabilitation services, physical therapy, home care, etc. in collaboration with physician and/or nurse expertise.
· Attends mediations and conducts on-site visits with agent/client and/or injured parties.
· Acts as trouble-shooter for complex issues that arise from the EDI system process. Assists in process development for paperless reporting (state driven).
· Utilizes cost containment programs, tools, and strategies as appropriate
· Composes correspondence and various reports in the management of workers compensation claims.
· Remains abreast of new case law decisions affecting workers compensation and disability management.
· Supports the team, as required, by acting as a back up to the Claims Examiner II & III.
· Acts as team and company liaison to field examiners.
· Ensures proficiency in litigation management and third party strategies and recoveries.
· Determines needs for independent medical evaluations.
· Update databases and prepares reports utilizing standard software.
· Maintains confidentiality of information processed
· Ability to perform other assignments at locations outside the office as needed
· Works with minimum supervision.
· Directs claims administration efforts within statutory, procedural, case law, contractual and/or philosophical guidelines
· Manages the administration of complex claims and catastrophic exposures, within authority, including claims generated from dedicated large accounts
· Negotiates and settles claims with claimants and/or attorneys, within authority, at the earliest possible point to bring cases to final disposition. Exercises sufficient and independent judgement to settle cases prior to mediation and/or litigation.
· Actively participates in the agent/client management process; participates in securing new business and retaining existing business.
· Develops relationships with agent/clients for the team’s block of business
· Assists in the development of agent/client planning, reporting, analysis and conducts education & training programs
· Serves as liaison for the Regional Team with agent/clients in supporting case management initiatives
· Engages in assisting the mentoring of other team members
· Represents the Regional Team on various committees and projects
· Provides leadership regarding case law understanding for regional team
This position description identifies the responsibilities and tasks typically associated with the performance of the job. Other relevant essential functions may be required.
Requirements
EMPLOYMENT QUALIFICATIONS:
EDUCATION OR EQUIVALENT EXPERIENCE:
Bachelor’s degree in insurance, business or related field. Progress towards, or completion of, industry-recognized professional designations preferred. Combinations of relevant education and experience may be considered.
EXPERIENCE:
Three years experience in an insurance organization with demonstrated technical knowledge in one or more of the following areas: claims account management, medical/vocational management, or underwriting, auditing or similar knowledge that provide the necessary skills and abilities. Workers compensation insurance administration experience required. Bi-lingual preferred.
***MUST HAVE EXPERIENCE WORKING WITH ILLINOIS STATE WORKER'S COMPENSATION CLAIMS ***
SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:
· Ability to function effectively in a multi-functional team environment.
· Knowledge of appropriate jurisdictional workers compensation laws.
· Knowledge of the applicability of relevant laws and regulations.
· Knowledge of medical and legal terminology.
· Ability to establish and maintain an effective working and client relationship.
· Ability to analyze all details of a workers compensation claim and, based on this analysis, make efficient and effective decisions.
· Ability to negotiate and establish a personal rapport with opposing parties and to resolve conflicts in a professional manner.
· Ability to manage multiple priorities; establish work flows and meet necessary deadlines.
· Ability to effectively communicate verbally with providers, attorneys, agents and policyholders.
· Ability and proficiency in the use of computers and company standard software specific to position.
· Ability to prepare written communications, summaries, and reports
· Ability to work with minimum supervision.
· Ability to maintain confidentiality as appropriate.
· Ability to comprehend the consequences of various problem situations and address them, or refer them for appropriate decision making.
· Ability to effectively exchange information clearly and concisely, and present ideas, reports facts and other information, and respond to questions as appropriate.
· Ability to be innovative and creative when presented with roadblocks.
· Thorough knowledge of appropriate jurisdictional workers compensation laws
· Awareness of the American with Disabilities Act and the Family Medical Leave Act as it may apply to necessary accommodations and/or light duty
· Thorough knowledge of the applicability of relevant laws and regulations.
· Excellent oral and written communication skills with the ability to effectively communicate with providers, attorneys, agents and policyholders.
· Ability to interact with others to build consensus and get decisions implemented.
· Ability to solve practical problems and deal with a variety of variables in situations where only limited standardization exists.
· Ability to assist in training and mentoring of others
· Ability to make competent, independent decisions.
WORKING CONDITIONS:
Work is performed in an office setting with no unusual hazards. Travel is required.
