Workers' Compensation Specialist/Sr. Workers' Compensation Specialist

About the role

The Workers' Compensation Specialist/Senior Workers’ Compensation Specialist manages a caseload of excess workers’ compensation claims, focusing on complex and catastrophic claims. This role also oversees TPAs and claims processes in both the Primary Workers’ Compensation (PWC) and Excess Workers’ Compensation (EWC) Programs.

Responsibilities

• Review all newly reported excess reportable claims.
• Complete regular diary reviews of all claims within their respective caseloads.
• Ensure claim files are reserved in accordance with OSIP Regulations and most probable value of the claim.
• Evaluate medical care and allocate/contribute potential.
• Manage and influence on PWC claims, even those not yet excess reportable.
• Communicate member or TPA concerns and provide solutions.
• Attend and provide input for settlement conferences, defense counsel meetings, and court hearings.
• Present cases and settlement recommendations to PWC and Claims Review Committees (CRC).
• Participate in regular file reviews and provide recommendations for improving claims services.
• Provide training to members and TPAs.
• Support PRISM Core Values and Mission.
• Assist in completing organizational goals and objectives.

Requirements

• Understanding of California Workers’ Compensation laws and familiarity with excess and pooled risk programs.
• Experience working with TPAs, legal counsel, and insurance or reinsurance entities.
• Ability to assess medical treatment plans, reserves, and settlement values.
• Strong written and verbal communication skills for reporting and presentation to committees.
• Proficient in Microsoft Office Suite and experience with claims management systems.
• Willingness and ability to travel occasionally for member file reviews, trainings, or conferences.

Qualifications - Specialist Level

• Minimum of 3 years of experience of direct handling of California workers’ compensation claims including future medical files and preferably indemnity claims.
• Associate’s or Bachelor’s degree in Business Administration, Risk Management, Public Administration, or a related field.
• California Self-Insurance Plans Certificate preferred.
• Coursework or certification in Workers’ Compensation Claims, Risk Management, or a related area is desirable.
• Strong interpersonal and customer service skills; ability to interact professionally with members, TPAs, and other stakeholders.
• High level of integrity, professionalism, customer service, attention to detail, and critical thinking.
• Experience working with public agencies or joint powers authorities (JPAs) is a plus.

Qualifications - Sr. Specialist Level

• Bachelor’s degree in Business, Public Administration, Risk Management, Insurance, or a related field.
• Minimum of 5 years of experience of direct handling of workers’ compensation claims including complex, litigated, catastrophic and excess claims.
• Workers’ Compensation Claims Administration Certification or Self-Insurance Administrator Certificate is strongly preferred.
• Strong analytical, communication, and interpersonal skills; ability to interact professionally with members, TPAs and other stakeholders.
• High degree of professionalism and customer service orientation.
• High level of integrity, professionalism, customer service, attention to detail, and critical thinking.
• Proven ability to mentor, train, and guide junior staff or peers.
• Experience with public agencies or joint powers authorities (JPAs) is a plus.

Benefits

A generous benefit package is provided including Public Employees Retirement System (PERS) health benefits, dental, vision, long-term disability, life insurance, PERS retirement, deferred compensation program, sick leave, vacation leave, and section 125 cafeteria benefits.