Claims Specialist, Workers' Compensation and Unemployment

Location:

Department:

Weekly Hours:

Status:

Shift:

Job Summary:

The workers compensation and unemployment claims specialist is responsible for the management and oversight of workers compensation and unemployment claims. This includes ensuring compliance with applicable regulations coordinating claim investigations facilitating timely resolution and implementing strategies to minimize risk and financial exposure.

ACCOUNTABILITIES

• Claims Evaluation Investigation & Management:
• Bill Review Processing
• OSHA Recordkeeping
• Administrative functions

Claims Evaluation Investigation & Management:

• Serve as a primary point of contact for claims and inquiries
• Assess claim to determine compensability and conduct thorough investigation to gather all pertinent information prior to claim determination. Ensure timely review and submit claims along with the organizations position on compensability to the appropriate state agency.
• Collaborate with Human Resources (HR) business partners and supervisors to obtain and verify documentation regarding employment details Leave of Absence (LOA) referrals and confirm return-to-work status for both light-duty and full-duty assignments.
• Assess and establish claim exposure to set/review reserves for insured and self-insured claims.

• Calculate and process indemnity benefits to injured employees.
  • Determine the necessity and obtain manager approval of vendor services such as medical case management surveillance vocational rehabilitation services medical and pharmaceutical reviews and Independent Medical Evaluations (IMEs) to ensure effective cost containment of expenses on claims and for compliance with state laws and organizational policies.
  • Assist legal counsel in preparation of Unemployment and Workers Compensation cases and attend hearings if necessary.
  • Monitor claim status review treatment plans to determine appropriateness based on the employees accepted condition.
  • Evaluate initiate and negotiate full and final claim settlements when appropriate.
  • Analyze claim trends and provide recommendations to reduce exposure and costs.

Bill Review Processing:

• Review invoices and process according to state fee schedule guidelines.
• Oversee and submit invoices to the bill review vendor for processing in accordance with established procedures.
• Enter credits and recoveries into the appropriate claim records.

OSHA Recordkeeping:

• Monitor and audit employee events for determination of recordable events.

Administrative functions:

• Maintain accurate records of claims and related correspondence
• Filing
• Copying
• Scanning
• Distribution of mail

REQUIRED QUALIFICATIONS

Education: Associates degree or equivalent combination of education and relevant insurance claim management experience.

Skills:

• Proficient in all MS Office applications.
• Demonstrated knowledge of workers compensation claims management or unemployment.
• Excellent verbal written and interpersonal communication skills.
• Ability to build trust and credibility with all levels of employees across the organization.
• Able to work in a high-energy fast-paced environment.
• A high level of confidentiality and demonstrated good judgment.

Years of Experience: Mid-Level professional with 3 years of Workers Compensation claims management experience.

PREFERRED QUALIFICATIONS

Skills:

• Comprehensive understanding of Risk Management or claims handling.

Years of Experience: Mid-Level professional with 5 years of Workers Compensation and Unemployment claims management experience. 1 years of experience in medical case management risk management or human resources experience.

WORKING CONDITIONS

Physical Demands: Sedentary. May be long periods of sitting and or walking throughout work location.

The above list of accountabilities is intended to describe the general nature and level of work performed by the positions; it should not be considered exhaustive.

Qualified applicants will receive consideration for employment without regard to race color national origin ancestry religion sex/gender (including pregnancy) sexual orientation gender identity or gender expressionage physical or mental disability military or protected veteran status citizenship familial or marital status genetics or other status protected by applicable law.

Equal Opportunity Employer/Drug-Free Workplace

ProMedica is a mission-driven not-for-profit health care organization headquartered in Toledo Ohio. It serves communities across nine states and provides a range of services including acute and ambulatory care a dental plan and academic business lines. ProMedica owns and operates 10 hospitals and has an affiliated interest in one additional hospital. The organization employs over 1300 health care providers through ProMedica Physicians and has more than 2300 physicians and advanced practice providers with privileges. Committed to its mission of improving health and well-being ProMedica has received national recognition for its clinical excellence and its initiatives to address social determinants of more information about ProMedica please visit provide flexible benefits that include compensation and programs to help you take care of your family your finances and your personal well-being. Its what makes us one of the best places to work and helps our employees live and work to their fullest potential.

Qualified applicants will receive consideration for employment without regard to race color national origin ancestry religion sex/gender (including pregnancy) sexual orientation gender identity or gender expression age physical or mental disability military or protected veteran status citizenship familial or marital status genetics or any other legally protected compliance with the Americans with Disabilities Act Amendment Act (ADAAA) if you have a disability and would like to request an accommodation in order to apply for a job with ProMedica please contact

Equal Opportunity Employer/Drug-Free Workplace