Job Title: Claims Specialist - Workers' Compensation Department: Risk Management Reports To: Vice President of Risk Management FLSA Status: Exempt
Summary:
Highly organized professional to examine, adjust, and manage claims for workers' compensation benefits. This position includes maintaining internal records for Bureau of Workers' Compensation claim files. Essential Duties and Responsibilities: - Reviews injury reports to determine compensability.
- Examines workers' compensation claim forms.
- Advises employers on the proper management and impact of workers' compensation claims. Explains operation of alternate "light work" programs.
- Arranges for the payment of medical bills, temporary and permanent disability compensation, and death benefits (Self-Insured).
- Consults with medical staff (MCO) and legal counsel as required.
- Provides information to employees/claimants about workers' compensation benefits.
- Maintains data bases for workers' compensation files. Summarizes reports as required for annual statistics.
- Authorizes hospitalization, surgery, and other types of treatment as required (Self-Insured).
- Approves benefit payments as well as payment of medical and legal expenses.
- Assists GMS attorneys as required in handling litigated claims, and follows up on subrogation claims. Prepares weekly hearing docket file for GMS Attorney.
- Schedules Independent Medical Examinations (IME) and prepares IME letters.
- Follows up with clients as directed regarding status of WC Claims
- Prepares Handicap Reimbursement Letters and handles phone hearings
- Maintains database and spreadsheet regarding all hearing results
Qualifications: - To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability preferred. Training will be provided. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- At least two years' experience as a workers' comp claims specialist processing claims under supervision.
- Knowledge of state workers' compensation laws as well as the procedures and regulations of the state.
- Knowledge of medical and technical terminology used in industrial cases.
- Ability to write case histories, reports, and letters.
- Ability to work with computer database systems to prepare reports.
- Speaking ability to make presentations to employer and employee groups to explain general rules of compensation system as well as particular case situations.
- Valid driver's license to visit workplaces to provide training about workers' compensation system.
Education and/or Experiences - Bachelor's degree (B.A.) from a four-year college or university; or 2-3 years related experience and/or training; or equivalent combination of education and experience.
Language Skills - Ability to read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents. Ability to respond to common inquiries or complaints from customers, regulatory agencies,
- or members of the business community. Ability to effectively present information to management, public groups and/or clients.
Mathematical Skills - Ability to work with mathematical concepts such and probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
Reasoning Ability - Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
Computer Skills - Proficient in personal computer skills including electronic mail, record keeping, routine database activity, worked processing, spreadsheet, graphics, etc. This role requires an above-average knowledge of Microsoft Excel.
Physical Demands - The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
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