Claims Specialist

Texas Municipal League Intergovernmental Risk Pool•Austin, TX

15h•Onsite

About The Position

This position is responsible for investigating and managing Workers' Compensation claims to ensure accurate and timely benefit administration while safeguarding Members' pooled funds. It involves assessing claim compensability, coordinating medical treatment, and facilitating claim resolution in compliance with Texas Workers' Compensation regulations. This position also requires effective communication with injured workers, medical providers, and fund members to support fair and efficient claims handling.

Requirements

B.A. or B.S. degree in Business, Insurance, Risk Management, or related field
3 Years of Experience in Workers’ Compensation
Texas Department of Insurance All Lines or Workers’ Compensation Adjuster License
Valid Texas driver’s license and a good driving record
Possess knowledge and understanding of relevant laws, rules, and regulations
Excellent decision-making and problem-solving skills
Excellent oral and written skills
Proficiency in MS Excel
Proficiency in MS Word
Proficiency in MS PowerPoint
Proficiency in MS Outlook

Nice To Haves

Associate in Claims (AIC) designation from AICPCU/IIA
Experience in the Workers’ Compensation Insurance Industry
Experience driving and motivating cross-functional teams to successfully implement strategic or business projects
Strong business development skills and knowledge of small business operations
Proficiency in Adobe Creative Suite
Proficiency in MS Visio
Proficiency in MS Access

Responsibilities

Conducts thorough investigations of Workers' Compensation claims to determine compensability, including interviews with Members, claimants, and witnesses, and reviews medical reports, personnel files, and other relevant documents.
Calculates and administers indemnity benefits, including Temporary Income Benefits (TIB), Impairment Income Benefits (IIB), Supplemental Income Benefits (SIB), Death Benefits (DB), Lifetime Income Benefits (LIB), multiple employment, adjusted benefits, and benefits checks with multiple payees in accordance with the Texas Workers' Compensation rules.
Maintains and manages claims to conclusion by coordinating with Members, medical providers, preauthorization, and injured workers to drive claims towards resolution.
Effectively document the claim file per the Pool’s Service Level Objectives.
Coordinates with vendors for the management of Peer Reviews, Designated Doctor (DD) exams, and Post-DD Required Medical Examinations.
Ensure compliance with doctor's orders, medical instructions, and the Texas Labor Code.
Prepares cases for dispute resolution and participates in hearings and dockets to support claim resolution.
Handles incoming communications, including phone calls and emails, and ensures the accuracy of documents received from fund members, requesting corrections when necessary.
Shares responsibility for the emergency after-hours line.
Assists in training and educating Members on Workers’ Compensation processes and procedures.
Conducts periodic eligibility checks on beneficiaries to verify continued qualification for benefits.
Submits required documentation to the Division of Workers' Compensation within mandated deadlines.
Reviews and processes incoming documents, including legal and expense invoices, medical bill payments, travel reimbursements, and work status reports, while maintaining organized and properly labeled claim files.