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Worker's Compensation Claims Specialist in Lansing, MI at AF Group

Date Posted: 6/26/2018

Job Snapshot

Job Description

Medical Only Claims Specialist Worker's Compensation- Lansing

Primarily responsible for the investigation and management of workers' compensation claims. Conducts a 1 to 3 point contact on the managed claims, which is dependent on either the facts of the case or the claim type; determines compensability of claims, manages the medical treatment program, and assists in the return-to-work process. This includes calling and discussing potential claim activity and work-related injuries with policyholders, claimants, providers, attorneys, agents, and state agencies. Provides backup support to other MOCS and Claims Representatives; trains and mentors other team members.


  • Investigates workers' compensation claims with a mandatory contact to the employer within the required time frame with additional contacts to the employee or provider, as necessary.
  • Determines the compensability of medical only and pay and close indemnity claims by thorough investigation of the claim.
  • Determines and manages the on-going medical treatment program including directing care, creating panels and approving provider requests.
  • Remains abreast of new case law decisions affecting claim and medical management.
  • Handles telephonic mediations to address litigated issues.
  • Monitors the work status of the claimants.
  • May serve as an adjuster to the dedicated account representative.
  • Evaluates medical reports and correspondence for appropriate action/documentation.
  • Supports the customer service work and processes for the multi-functional claims team; Communicates and collaborates with team members to ensure the appropriate and timely handling of claims in other states.
  • Supports the team, as required, by acting as a back up to the Service Center, MOCS, and Claims Representatives.
  • Mentors fellow team members and assists in the development of individual career paths.
  • Establishes timely and appropriate reserves based on the profile of the claim within given authority based on anticipated financial exposure.
  • Verifies workers' compensation coverage of employers and injured employees.
  • Determines causal relationship between the reported injury and the incident to ensure appropriate payment of benefits.
  • Documents specifics of claims with potential for subrogation recovery, including amount of potential recovery monies.
  • Manages medical bills for non-idemnity and indemnity claims directly associated with the claimed injury. Approves payment based on knowledge of the treatment plan and medical support showing relationship of treatment to the injury.
  • Concludes and closes files following resolution of claims to meet internal performance standards while complying with state legislation to avoid penalties and manage expenses.
  • Works closely with manager on complex files or files above reserve authority.
  • Coordinates with outside vendors to ensure cost containment efforts.
  • Establishes and maintains effective working relationships with all internal and external customers.
  • Coordinates the Care Analytics and causation investigation initiatives as deemed appropriate by using tools such as Thru Time model, Claim Outcome model, Claim Predict Litigation models, and pharmacy program.
  • Determines appropriate response to regulatory inquiries.
  • Composes correspondence and various reports in the administration of workers compensation claims; sets appropriate diaries.
  • May attend agent and/or policyholder visits.
  • Conducts employee-employer interviews to assist in the return-to-work process.
  • Supports the account management process appropriately for the team's block of business.
  • Recommends independent medical evaluations within authority.
  • Reads, routes and keys incoming mail, runs reports and answers/responds to incoming phone calls, faxes and emails.
  • Works with minimum supervision.





    EMPLOYMENT QUALIFICATIONS:



    EDUCATION REQUIRED:

    Associate degree in insurance and/or related field with progress towards or completion of Insurance Institute of America (IIA) or other insurance related designation(s). Combinations of education and experience may be considered in lieu of a degree.

    EXPERIENCE REQUIRED:

    Minimum of five (5) years workers compensation experience, including three (3) years of demonstrated technical knowledge (i.e. applying relevant workers compensation laws, regulations, guidelines, and/or policies that would impact claims and/or underwriting outcomes) required. Relevant customer service experience exchanging information and answering and resolving inquiries over the phone required.

    OR

    Bachelor's degree in insurance and/or related field with progress towards or completion of Insurance Institute of America (IIA) or other insurance related designation(s) and three years of insurance experience including two years experience as a claims representative with experience in reviewing, investigating, and managing claims.



    SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:




  • General knowledge of claims operations specifically claims processes.
  • Ability to work effectively in a multifunctional business unit.
  • Excellent verbal and written communication skills.
  • Ability to use diplomacy, discretion, and appropriate judgment when responding to inquiries from staff and external customers as well as anticipating needs of the department.
  • Ability to effectively exchange information clearly and concisely, and present ideas, report facts and other information and respond to questions as appropriate.
  • Knowledge of Workers Compensation in one or more states including jurisdictional laws.
  • Basic knowledge of statutory standards in multiple states.
  • Ability to apply relevant workers' compensation laws and regulations, including jurisdictional laws.
  • Ability to negotiate, build consensus, and resolve conflict.
  • Excellent organizational skills and ability to prioritize work.
  • Ability to manage multiple priorities and meet established deadlines.
  • Ability to perform mathematical calculations.
  • Excellent analytical and problem solving skills.
  • Ability to use reference manuals.
  • Knowledge of medical terminology.
  • Knowledge of legal terminology.
  • Ability to comprehend various claims issues, address them or refer them for appropriate decision-making.
  • Ability to analyze details of workers compensation claims and as a result able to make competent, independent decisions within authority.
  • Ability to work with minimal direction.
  • Ability to travel to locations outside of the office.
  • Ability to proofread documents for accuracy of spelling, grammar, punctuation and format



    ADDITIONAL EDUCATION, EXPERIENCE, SKILLS, KNOWLEDGE AND/OR ABILITIES PREFERRED:


  • Knowledge and experience of claims adjusting, including investigations, determining compensability, and medical management of claims highly preferred.
  • Claims adjuster certification is highly preferred and encouraged.

    IMPORTANT:

    For this posting, due to staffing and workload needs, an additional requirement has been added.


  • Candidates must have a current Claims Adjuster License or must obtain a Claims Adjuster License within 90 calendar days after placement in this position.
  • Failure to obtain a Claims Adjuster License within 90 calendar days after placement will result in a failure of Trial period, (Section 9.6.1 of CBA) which states that "the employee will be disqualified from the position. In these instances, initially, the employee will be placed on the recall list in accordance with Article 8.8 of the Collective Bargaining Agremeent and will be provided recall rights at the pay range of the job held before the trial period."




    WORKING CONDITIONS:



    Work is performed in an office setting with no unusual hazards. Travel may be required.

    REQUIRED TESTING:

    Reading Comprehension, Typing 35 wpm, Basic Word, Math and Proofreading.

    Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled
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