Claims Specialist, Workers Compensation

Duties and Responsibilities

• Act as the primary point of contact for clients regarding workers’ compensation claims.
• Advocate for aggressive investigation of questionable claims and use of sub-rosa surveillance when appropriate.
• Monitor open claims to ensure timely and appropriate handling by Carriers/TPAs.
• Provide guidance on claim strategy and resolution options.
• Identify opportunities for claim closure, cost containment, and fraud prevention.
• Assist clients in understanding claim status, medical treatment plans, and return-to-work strategies.
• Educate clients on the use of Medical Provider Networks (MPNs) and help identify quality care providers.
• Work with clients and Carriers/TPAs to establish and enforce claims handling protocols.
• Evaluate Carriers/TPAs bill review and utilization review programs.
• Ensure quarterly claim reviews are conducted (In-person or teams meeting as appropriate), assist in preparing claim summaries, and presentations for client meetings.
• Ensure that a quarterly claim review is conducted close to unit stat filing date.
• Complete WC Claim Call Reports that are professional in appearance and consistent in accordance with established standards and provide copies to Producers to support client discussions.
• Review and analyze loss runs, claim trends, and reserve accuracy.
• Prepare projected experience mods ratings and using the established format to explain increase or decrease.
• Stay current on legislative changes and industry trends affecting workers’ compensation.
• To ensure claims are managed in accordance with state regulations.
• Aid Trucordia Account Managers in obtaining experience rating worksheets and responding to WC claim questions.
• Provide training and resources to clients on workers’ compensation procedures and process, including the interactive process when returning an employee to work with permanent work restrictions.
• Collaborate with Producers and Account Managers to support client retention and new business development.

Qualifications

• Bachelor's Degree or higher is desired but not required if appropriate work experience is present
• 7-10+ years CA workers’ compensation claims handling or consulting - required
• SIP certificate required
• Strong understanding of CA WCAB processes, reserves, litigation strategy - required
• Ability to interpret loss runs, mod worksheets, and actuarial data
• Excellent communication skills - both written and oral
• Proficiency with Excel, Word, and RMIS platforms
• The ability to be a team player and proactively support others