Workers Compensation Return to Work Claim Professional - Cleveland OH

About the role

The opportunity involves managing Workers' Compensation claims with lost time to conclusion, negotiating settlements, coordinating medical and indemnity positions with a Medical Case Manager, and independently handling claims of low to moderate complexity.

Responsibilities

• Conduct investigations, including assessing policy coverage, contacting insureds, injured workers, medical providers, and other parties 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).
• Achieve a positive end result by returning injured party to work and coordinating the appropriate medical treatment.
• Work in collaboration with internal nurse resources and specialty resources (i.e. medical and legal) to proactively pursue claim resolution opportunities.
• 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 internal nurse resources 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.

Requirements

• 2 years Workers Compensation Claim Handling Experience.
• 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.
• Maintain Continuing Education requirements as required or as mandated by state regulations.

Qualifications

• High School Diploma or GED.
• 1 year Workers Compensation claim handling experience or successful completion of the WC trainee program.