Workers Compensation Critical Claim Specialist Jobs

Communicate with manager on claims above authority granted.

Participate in OR's Managed Care Excellence Group as requested.

Ensure TPA compliance with our best claim practices.

Provide direction to TPA as needed.

Act as liaison between insureds and TPA as needed.

Review/ approve reserves on assigned claims.

Knowledge of all lower level claim position responsibilities.

Career development: CCMSI offers robust internships and internal training programs for advancement within our organization.

Provide education, training and assist in the development of claim staff.

Excellent oral and written communication skills.

Good analytic and negotiation skills.

Must be detail oriented and a self-starter with strong organizational abilities.

Maintain Continuing Education requirements as required.

Apply knowledge to determine causal relatedness of medical conditions.

If controverted or coverage is unconfirmed, retain and manage assigned claims to conclusion.

Proactively manage inventory with documented plans of action to ensure timely and appropriate file closing or reassignment.

Manage litigation to drive files to an optimal outcome.

3+ years Workers Compensation claim handling experience preferred.

Assist in the selection, referral and supervision of designated claim files sent to outside vendors. (i.e. legal, surveillance, case management, etc.)

Career development: CCMSI offers robust internships and internal training programs for advancement within our organization.

Five or more years claims experience is required.

Investigate, evaluate and adjust claims in accordance with established claim handling standards and laws.

Establish reserves and/or provide reserve recommendations within established reserve authority levels.

Negotiate settlements in accordance within Corporate Claim Standards, client specific handling instructions and state laws, when appropriate.

Excellent time management skills with a proven ability to meet deadlines.

Provides local management with notices of absence and notices of return to work.

Excellent verbal and written communication skills.

Excellent interpersonal and customer service skills.

Excellent organizational skills and attention to detail.

Strong analytical and problem-solving skills.

Compile the region’s safety-related Key Performance Indicator (KPI) data for corporate and region management review

Perform accident / incident investigations to determine immediate cause as well as root cause; recommend changes to correct and prevent reoccurrence.

Process the region’s Certificate of Insurance (COI) requests from customers, contractors and other stakeholders

Assist in the formulation of general safety policies and procedures in compliance with local, state, and federal rules and regulations.

Must possess valid state driver's license, clean driving record, and appropriate level of auto insurance coverage.

Your differences enhance our performance

Skill in communicating findings, evaluations, problem resolution and recommendations with national level management, staff, outside experts, and health care providers.

Experience training healthcare providers and other stakeholders regarding medical billing and coding requirements.

Requires a probationary period if the requirement has not been met.

Experience in healthcare billing and coding practices, coding systems for medical services, healthcare delivery systems and medical bill processing systems

Experience monitoring payments, payment systems, billing, and coding to identify and make recommendations on potential weaknesses in payment systems

There is no substitution of education for the

Detail-oriented with strong organizational and time management abilities.

Collaborate with the ownership team to ensure seamless operations and efficient referral management.

Identify and target potential referral sources, including employers, adjusters, nurse case managers, attorneys, and funding companies.

Conduct sales presentations and product demonstrations to showcase the benefits of our workers' compensation services.

Utilize persuasive communication skills to negotiate partnerships and secure referrals.

Stay updated on workers' compensation regulations and compliance requirements.

Sharp analytical and critical thinking skills.

Proofreading and professional writing skills.

This is a full-time remote position.

Important Traits And Skills For The Position

Process revision and correction requests Keep clients, attorneys, nurses and supervisors updated regularly on report status.

Analyze and solve client issues quickly and efficiently in a fast paced environment.

Works collaboratively within and across business units and demonstrates proves experience with conflict management and influencing skills

Ability to build credibility and trust with employees, HR and management

Demonstrated effective communication skills with all levels of the organization to ensure all parties understand their responsibilities during an individual’s absence

Coordinate leaves concurrent with disability and workers compensation benefits, engaging other stakeholders as appropriate including benefits and legal staff

PHR, SPHR, CEBS, or other HR certification preferred

2-3 years of HR experience preferred and 3 years experience in leave administration, preferably in a multi-state environment

Specific Knowledge, Skills, or Abilities:

c License or Certification Required:

Equipment, Machinery, Tools, and Materials Utilization:

Career development: CCMSI offers robust internships and internal training programs for advancement within our organization.

Excellent oral and written communication skills.

Individual must be a self-starter with strong organizational abilities.

Investigate and adjust workers compensation claims in accordance with established claims handling procedures using CCMSI guidelines and direct supervision.

Negotiate settlements with claimants and attorneys in accordance with client's authorization.

Assist in selection and supervision of defense attorneys.

Stays current on knowledge related to the Workers' Compensation program

Check Out Our Outstanding Benefits!

APPLICANTS MUST MEET THE REQUIREMENTS AND ACHIEVE A PASSING SCORE OF 70% OR HIGHER ON

disqualification or rescission of appointment

Assists in resolving complaints/problems related to Workers’ Compensation

Assists in developing new or updating current Workers’ Compensation programs, policies, and procedures

Bachelor’s Degree preferred or a minimum of 2 years of work OR customer service related experience preferred.

Verbal and written communication skills –Intermediate

High School Diploma or GED and one year of customer service experience OR Bachelor’s Degree required.

The on the job training includes practice and execution and coaching on the following core assignments:

Pursue all offset opportunities, including apportionment, contribution and subrogation. Evaluate claims for potential fraud.

Participate in Telephonic and/or onsite File Reviews.

Assist in the selection, referral and supervision of designated claim files sent to outside vendors. (i.e. legal, surveillance, case management, etc.)

Knowledge of all lower level claim position responsibilities.

Career development: CCMSI offers robust internships and internal training programs for advancement within our organization.

Excellent oral and written communication skills.

Good analytic and negotiation skills.

Must be detail oriented and a self-starter with strong organizational abilities.

Maintain Continuing Education requirements as required.

5+ years Workers Compensation experience strongly preferred.

Medical knowledge: Thorough knowledge of the nature and extent of injuries, periods of disability, and treatment needed.

Minimum of 5 years Workers Compensation experience.

May use structured settlement/annuity as appropriate for the jurisdiction.

Facilitate timely claim resolution by leveraging any mitigation opportunities.