Workers Compensation Return to Work Case Manager - Richmond, VA

Military Spouse Corporate Career Network•Richmond, VA

2d•Onsite

About The Position

This role involves managing Workers' Compensation claims with lost time to conclusion, including negotiating settlements where appropriate. The Case Manager will coordinate the medical and indemnity aspects of the claim with a Medical Case Manager. The position independently handles assigned claims of low to moderate complexity where wage loss is present and the expectation is a return to work (modified or full duty) or achieving Maximum Medical Improvement (MMI) with no Return to Work (RTW). These claims typically do not involve litigated issues or only minor to moderate litigated issues and may include minor sprains or minor to moderate surgeries. The injured worker might be on modified duty with ongoing medical treatment, or may have returned to work, reached MMI, and is receiving Permanent Partial Disability (PPD) benefits, with the file closing after PPD payout. With moderate supervision, the role may also manage claims of greater complexity, such as when the injured worker remains out of work and unlikely to return to their position, the employer cannot accommodate restrictions, or the claim involves moderate to complex litigation. This includes claims where the injured worker has returned to work, reached MMI, has PPD, and the file is litigated to dispute the permanency rating and/or causality. It also covers situations where the injured worker is released to work with permanent restrictions and there's a change in their current position, or the injured worker is receiving Vocational Rehabilitation. Claims reopened for additional medical treatment on more complex files, injuries involving multiple surgeries (back, shoulder, knee), knee replacements, claims with moderate to complex offsets, permanent restrictions, or fatalities, and claims where a settlement should be considered also fall under this scope. The position requires maintaining insurance licenses as mandated by state and company requirements, including ongoing continuing education.

Requirements

2 years Workers Compensation claim handling experience.
High School Diploma or GED.
1 year Workers Compensation claim handling experience or successful completion of the WC trainee program.
Analytical Thinking: Identifies current or future problems or opportunities; analyzes, synthesizes and compares information to understand issues; identifies cause/effect relationships; and explores alternative solutions that support sound decision-making.
Communication: Expresses, summarizes and records thoughts clearly and concisely orally and in writing by applying proper content, format, sentence structure, grammar, language and terminology. Ability to effectively present file resolution to internal and/or external stakeholders.
Negotiation: Intermediate ability to understand alternatives, influence stakeholders and reach a fair agreement through discussion and compromise.
General Insurance Contract Knowledge: Interprets policies and contracts, applies loss facts to policy conditions, and determines whether or not a loss comes within the scope of the insurance contract.
Principles of Investigation: Intermediate investigative skills including the ability to take statements. Follows a logical sequence of inquiry with a goal of arriving at an accurate reconstruction of events related to the loss.
Value Determination: Intermediate ability to determine liability and assigns a dollar value based on damages claimed and estimates, sets and readjusts reserves.
Settlement Techniques: Intermediate ability to assess how a claim will be settled, when and when not to make an offer, and what should be included in the settlement offer package.
Legal Knowledge: General knowledge, understanding and application of state, federal and regulatory laws and statutes, rules of evidence, chain of custody, trial preparation and discovery, court proceedings, and other rules and regulations applicable to the insurance industry.
Medical knowledge: Intermediate knowledge of the nature and extent of injuries, periods of disability, and treatment needed.
WC Technical: Intermediate ability to demonstrate understanding of WC Products and ability to apply available resources and technology to resolve claims.
Demonstrate a clear understanding and ability to work within jurisdictional parameters within their assigned state.
Intermediate knowledge, understanding and application of state, federal and regulatory laws and statutes, rules of evidence, chain of custody, trial preparation and discovery, court proceedings, and other rules and regulations applicable to the insurance industry.
Customer Service: Advanced ability to build and maintain productive relationships with our insureds and deliver results with optimal outcomes.
Teamwork: Advanced ability to work together in situations when actions are interdependent and a team is mutually responsible to produce a result.
Planning & Organizing: Advanced ability to establish a plan/course of action and contingencies for self or others to meet current or future goals.
Maintain Continuing Education requirements as required or as mandated by state regulations.

Responsibilities

Manage Workers' Compensation claims with lost time to conclusion and negotiate settlements where appropriate to resolve claims.
Coordinate medical and indemnity position of the claim with a Medical Case Manager.
Independently handle assigned claims of low to moderate complexity where Wage loss and the expectation is a return to work to modified or full duty or obtain MMI with no RTW.
Conduct investigations, including assessing policy coverage, contacting insureds, injured workers, medical providers, and other parties in a timely manner to determine compensability.
Establish and update reserves to reflect claim exposure and document rationale.
Identify and set actuarial reserves.
Apply knowledge to determine causal relatedness of medical conditions.
Manage files with an emphasis on file quality (including timely contact and proper documentation and proactive resolution of outstanding issues).
Achieve a positive end result by returning injured party to work and coordinating the appropriate medical treatment in collaboration with internal nurse resources where appropriate.
Work in collaboration with specialty resources (i.e. medical and legal) to proactively pursue claim resolution opportunities (i.e. return to work, structured settlement, and discontinuation of benefits through litigation).
Develop strategies to manage losses involving issues of statutory benefit entitlement, medical diagnoses, Medicare Set Aside to achieve resolution through the best possible outcome.
Collaborate with our internal nurse resources (Medical Case Manager) in order to integrate the delivery of medical services into the overall claim strategy.
Prepare necessary letters and state filings within statutory limits.
Pursue all offset opportunities, including apportionment, contribution and subrogation.
Evaluate claims for potential fraud.
Proactively manage inventory with documented plans of action to ensure timely and appropriate file closing or reassignment.
Effectively manage litigation to drive files to an optimal outcome, including resolution of benefits.
Understand and apply Medicare Set Asides and allocations.
Negotiate settlement of claims within designated authority.
May use structured settlement/annuity as appropriate for the jurisdiction.
Perform other duties as assigned.