Categories: Human Resources, Risk Management, Insurance

The WC Claims Specialist is responsible for claims management and issues related to work comp. This position works under general supervision; exercises discretion and relies on experience and judgment to plan and accomplish goals; and requires a certain degree of creativity and autonomy to perform the job.

Principal Duties and Responsibilities

• Serves as primary contact for the field operations on WC related claim procedures and claims management issues

• May serve as a back-up for FMLA, ADA, and disability related claim procedures and claims management issues

• Assists with updating documentation and communication associated with related leaves of absences

• Trains new plant HR/safety personnel, including acquisitions, on related leave of absence procedures

• Produces quarterly trend reports and other related reports as requested

• Assists with monitoring federal and state leave regulations and with working with vendors and plants to implement any necessary updates to existing procedures

• Monitors claim activity to ensure timely and accurate delivery of benefits

• Provides assistance to the field regarding medical management and return to work

• Reviews claim data to ensure that claims are managed, paid, and resolved according to service criteria

• Ensures that all claims are reviewed for appropriateness of acceptance or denial

• Advises the field in identifying and maintaining quality medical providers

• Assists in the identification of legal counsel with assistance from the claim managers/TPA

• Assists in developing legal strategy for each litigated case

• Advises the field in transitional and long-term return-to-work strategies

• Ensures that the claim managers/TPA pay medical bills and other related invoices promptly

• Provides guidance and related training to plant personnel with work comp responsibilities

• Helps maintain documentation, legal evidence, and other related file administration

• Maintains updated knowledge of state comp laws or other legal changes impacting areas of responsibility

• Advises the field and claim managers/TPA in investigating aspects of serious or questionable claims

• Acts as a liaison between injured worker and TPA/carrier

• Prepares and participates in strategic claim resolution meetings

• Assists with providing information to TPA/legal counsel in response to subpoena requests

• May assist with training for other related areas of responsibility

• May assist with policy updates for related areas of responsibility

• May serve as backup for Substance Abuse policy administration

• May serve as backup for other various safety related program administration

• Performs other duties as required.

Job Specifications

Knowledge

• Bachelor’s degree or equivalent experience in a related field

• Formal, working knowledge of claims management protocol and related employment law

• Some knowledge and understanding of medical terminology

Skills and abilities

• Ability to solve problems and apply knowledge and education in complex situations

• Ability to maintain and safeguard confidential information

• Verbal and written skills with the ability to communicate at all levels within the organization

• Interpersonal and problem-solving skills

• Demonstrated ability to use computers and related business software and experience with advanced excel or other report writing programs

• Ability to understand, analyze, and communicate financial information as a management tool

• Ability to coordinate and prioritize case load

• Ability to travel as required

Conduct

• Team player and goal oriented

• Leads by example