Senior Claims Specialist, Workers Compensation - Remote
About The Position
Examines claims data and conducts investigations into routine and moderately complex claims to determine coverage, compensability, subrogation and benefits under moderate supervisory direction. Adjusts and manages claims within the limit of assigned authority. Must be well versed in California Compensation statute claims. Receives lost time and complex medical only assignments. Verifies and determines applicability of coverage. Initiates 24-hour contact with employer, employee and 48-hour contact with attending physician. Handles catastrophic claims with supervisory oversight. Conducts telephone investigations as required by company claims handling manual and procedures. Evaluates and adjusts claims within the limits of authority. Consults with Claim Manager on those claims where assistance and consultation is needed. Makes assignments to nurse case management when indicated, monitoring their billing and performance. Sets reserves for anticipated exposure up to authority limits. Completes mandatory Reserve Worksheets. Establishes reserves requiring complex analysis with lifetime pharmacy and cost inflation. Coordinates return to work (RTW) and sets target dates. Maintain diaries on maximum three (3) month intervals. Documents files in the claims system. Reviews medical bills for causal relationship, medical bill charges for appropriateness and approves payments. Adheres to special account handling (SHI) instructions. Attends account meetings by telephone and in-person. Manages litigation on the files.
Requirements
- College degree, B.A. or equivalent experience.
- 3+ years experience handling workers compensation claims.
- Strong organizational skills.
- Good time management skills.
- Excellent verbal and written communication skills are essential.
- Strong aptitude and knowledge of Microsoft Office programs and the ability to quickly learn new programs.
- Will abide by departmental policies and procedures, including authority levels, to comply with C&F’s risk management controls.
Nice To Haves
- Foreign language communications a plus.
Responsibilities
- Examines claims data and conducts investigations into routine and moderately complex claims to determine coverage, compensability, subrogation and benefits under moderate supervisory direction.
- Adjusts and manages claims within the limit of assigned authority.
- Must be well versed in California Compensation statute claims.
- Receives lost time and complex medical only assignments.
- Verifies and determines applicability of coverage.
- Initiates 24-hour contact with employer, employee and 48-hour contact with attending physician.
- Handles catastrophic claims with supervisory oversight.
- Conducts telephone investigations as required by company claims handling manual and procedures.
- Evaluates and adjusts claims within the limits of authority.
- Consults with Claim Manager on those claims where assistance and consultation is needed.
- Makes assignments to nurse case management when indicated, monitoring their billing and performance.
- Sets reserves for anticipated exposure up to authority limits.
- Completes mandatory Reserve Worksheets.
- Establishes reserves requiring complex analysis with lifetime pharmacy and cost inflation.
- Coordinates return to work (RTW) and sets target dates.
- Maintain diaries on maximum three (3) month intervals.
- Documents files in the claims system.
- Reviews medical bills for causal relationship, medical bill charges for appropriateness and approves payments.
- Adheres to special account handling (SHI) instructions.
- Attends account meetings by telephone and in-person.
- Manages litigation on the files.
Benefits
- Competitive compensation package
- Generous 401K employer match
- Employee Stock Purchase plan with employer matching
- Generous Paid Time Off
- Excellent benefits that go beyond health, dental & vision. Our programs are focused on your whole family’s wellness, including your physical, mental and financial wellbeing
- Tuition reimbursement
- Industry-related certifications
- Professional training
- Matching donation program
- Volunteer opportunities
- Employee-driven corporate giving program
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
Associate degree
