Workes Compensation Claim Professional -Return To Work Case Mgr I

The Travelers Companies Indianapolis , IN 46218

Posted 3 months ago

Primary Job Duties & Responsibilities

Conduct investigations, including, but not limited to assessing policy coverage, contacting insured's, 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. Customer Engagement Participate in Telephonic and/or onsite File Reviews Respond to inquiries - verbal and written Keeping injured worker apprised of claim status Engage specialty resources as needed. Other duties as assigned

Job Specific & Technical Skills & Competencies

  • 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 insured's 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

Job Summary

Under moderate supervision, 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 handles 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. There are no litigated issues or minor to moderate litigated issues. The claim may involve minor sprains/ minor to moderate surgery The injured worker is working modified duty and receiving ongoing medical treatment.

The injured worker as returned to work, reached Maximum Medical Improvement (MMI) and is receiving PPD benefits. File will close as soon as the PPD is paid out. With close to moderate supervision, may handle claims of greater complexity where Injured worker (IW) remains out of work and unlikely to return to position.

Employer is unable to accommodate the restrictions. The claim involves moderate to complex litigation issues IW has returned to work, reached Maximum Medical Improvement (MMI), and has PPD. File litigated to dispute the permanency rating and/or causality.

IW has been released to work with permanent restrictions and job is no longer available. IW is receiving Vocational Rehabilitation. Claims that have been reopened for additional medical treatment on more complex files.

Injuries may involve one or multiple back, shoulder or knee surgeries, knee replacements, claims involving moderate to complex offsets, permanent restrictions and/or fatalities. Claims on which a settlement should be considered.

Education, Work Experience & Knowledge
1-2 years related business experience preferred College degree highly preferred.

Physical Requirements

Operates standard office equipment Sitting (Can stand at will) Use of Keyboards, Sporadic 10-Key

Minimum Qualifications

Required: High school diploma or equivalent required Minimum of 1 year related business experience (i.e., insurance , customer service, financial, banking) Strong understanding of Workers Compensation laws, coverage, and regulations required



See if you are a match!

See how well your resume matches up to this job - upload your resume now.

Find your dream job anywhere
with the LiveCareer app.
Download the
LiveCareer app and find
your dream job anywhere
lc_ad

Boost your job search productivity with our
free Chrome Extension!

lc_apply_tool GET EXTENSION

Similar Jobs

Want to see jobs matched to your resume? Upload One Now! Remove
RN Field Case Manager Team Lead Indianapolis

Sedgwick Claims Management Services, Inc.

Posted 4 days ago

VIEW JOBS 11/17/2018 12:00:00 AM 2019-02-15T00:00 Case Management Team Lead IF YOU CARE, THERE'S A PLACE FOR YOU HERE For a career path that is both challenging and rewarding, join Sedgwick's talented team of 21,000 colleagues around the globe. Sedgwick is a leading provider of technology-enabled risk, benefits and integrated business solutions. Taking care of people is at the heart of everything we do. Millions of people and organizations count on Sedgwick each year to take care of their needs when they face a major life event or something unexpected happens. Whether they have a workplace injury, suffer property or financial loss or damage from a natural or manmade disaster, are involved in an auto or other type of accident, or need time away from work for the birth of a child or another medical situation, we are here to provide compassionate care and expert guidance. Our clients depend on our talented colleagues to take care of their most valuable assets -- their employees, their customers and their property. At Sedgwick, caring counts®. Join our team of creative and caring people of all backgrounds, and help us make a difference in the lives of others. For nearly 50 years, Sedgwick has been helping employers answer virtually every question there is about workers' compensation. We have experience in nearly every type of industry, in every region, providing the broadest range of programs and services. PRIMARY PURPOSE: To ensure efficient, cost effective, and high quality delivery of case management services to clients for a single business line by supervising and training a staff of centralized case management specialists and overseeing the management of cases worked by field specialists; and to ensure customer satisfaction through the provision of these services and through dealing directly with workers compensation claims managers, supervisors and examiners utilizing the account management process. ESSENTIAL FUNCTIONS and RESPONSIBILITIES * Supervises, coordinates, and reviews the work of assigned staff for a single business line. * Acts as liaison between telephonic and onsite case management. * Participates in account support and management. * Assures achievement of unit financial goals and customer service/satisfaction goals. * Provides expert medical and product support to staff. ADDITIONAL FUNCTIONS and RESPONSIBILITIES * Performs other duties as assigned. * Supports the organization's quality program(s). SUPERVISORY RESPONSIBILITIES * Administers company personnel policies in all areas and follows company staffing standards and training recommendations. * Interviews, hires and establishes colleague performance development plans; conducts colleague performance discussions. * Provides support, guidance, leadership and motivation to promote maximum performance. QUALIFICATIONS Education & Licensing Current unrestricted RN license in a state or territory of the United State required. Bachelor's degree or higher in a health or human sciences field preferred. URAC-recognized certification in case management required. Experience Six (6) years of related experience or equivalent combination of education and experience required to include two (2) years of full time equivalent in direct clinical care to consumers and three (3) years of experience as a case manager. Supervisory experience preferred. Skills & Knowledge * Solid knowledge of medical case management * Knowledge of resources available regarding the regulations and parameters of third party reimbursement * Knowledge of statutory requirements of state's jurisdiction * Excellent oral and written communication, including presentation skills * PC literate, including Microsoft Office products * Leadership/management/motivational skills * Analytical and interpretive skills * Strong organizational skills * Excellent interpersonal skills * Excellent negotiation skills * Ability to work in a team environment * Ability to meet or exceed Performance Competencies WORK ENVIRONMENT When applicable and appropriate, consideration will be given to reasonable accommodations. Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines Physical: Computer keyboarding, travel as required Auditory/Visual: Hearing, vision and talking NOTE: Credit security clearance, confirmed via a background credit check, is required for this position. The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time. Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace WORKERS COMP - Required. Sedgwick Claims Management Services, Inc. Indianapolis IN

Workes Compensation Claim Professional -Return To Work Case Mgr I

The Travelers Companies