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
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
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
Team player and goal oriented
Leads by example
WC Claims Specialist • Grand Rapids, MI
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