Lost Time Claims Specialist, Workers' Compensation
Encova Insurance
Lost Time Claims Specialist, Workers' Compensation
Encova Insurance
full-time
Posted on:
Origin: • 🇺🇸 United States
Visit company websiteSalary
💰 $55,132 - $110,642 per year
Job Level
Mid-LevelSenior
About the role
- JOB OBJECTIVE: The Lost Time Claims Specialist, Workers’ Compensation primarily manages indemnity claims. The Lost Time Claims Specialist is responsible for the investigation, evaluation, and determination of compensability for work-related injury and disease claims following established guidelines to determine benefit eligibility. The Lost Time Claims Specialist also serves as a resource to Medical Only Claims Specialists and Claims Specialist Trainees. The position’s objective is to provide superior service in a cost-effective manner to achieve best possible outcomes as well as proactively collaborate across the enterprise to ensure alignment of objectives and foster continuous improvement. ESSENTIAL FUNCTIONS: 1. Evaluates and establishes an action plan to manage medical and indemnity benefits associated with injury and occupational disease claims to their most cost- effective conclusion. 2. Decides the outcome of the claim using sound judgment by applying established policy, procedures, regulations and guidelines. 3. Gathers facts by conducting interviews with all involved parties and considers all the elements of the claim prior to issuing a decision. 4. Take recorded statements when necessary. 5. Determines eligibility of indemnity and medical benefits once salary information and medical treatment plans have been secured and processed within the designated authority levels. 6. Utilize proactive reserving behaviors to ensure adequate case reserves which reflect the probable ultimate outcome based on the current known circumstances throughout the life of the claim. 7. Actively identifies and develops the investigation of and pursuit of subrogation recoveries when possible. 8. Consults with assigned claim director, return to work specialists, nurse case managers, internal/external medical, and legal on current and/or recommended treatment, litigation or rehabilitation plans to ensure claims outcomes are achievable and appropriate. 9. Works collaboratively with the injured worker, employer, outside counsel, and health and rehabilitation professionals to manage the claims costs and promote quality medical care. 10. Works collaboratively with the injured worker, employer, assigned return to work specialist, and medical providers to facilitate the injured worker’s safe and timely return to work. 11. Manages claims litigation, including expenses, by collaborating and providing direction to panel counsel throughout the life of the claim. 12. Analyzes reports from external resources such as physicians, attorneys, and/or vocational rehabilitation experts to evaluate and adjust claim strategies as needed. 13. Evaluates and negotiates claim settlements utilizing human relation skills and technical knowledge to achieve the best possible outcome. 14. Presents and summarizes claim details at internal team staffing, participates in discussions, and provides guidance as needed. 15. Consults with assigned claim director if the loss becomes significantly complex or presents significantly increasing financial exposure. 16. Follows established claims best practices related to medical management, litigation, fraud/abuse and recovery. 17. Effectively and independently uses available resources to prioritize, organize, and complete work in a timely manner to meet jurisdictional requirements, timeframes, and internal metrics. 18. Develops presentations for special projects such as internal/external meetings and conferences as needed. 19. Along with the claim director, regional vice president and other claims staff, participates in claim reviews, onboardings, etc. for our policyholders and agents. 20. Proactively collaborate with our policyholders to ensure alignment of objectives and foster continuous improvement. OTHER FUNCTIONS: 1. Nonessential function: other duties as assigned.
Requirements
- Bachelor’s Degree from an accredited college or university is preferred. Three years of experience in the field of workers’ compensation insurance required. Ability to manage claims through the litigation process. Internal candidates must demonstrate knowledge of Encova Best Practices guidelines and meet quality standards. One valid workers’ compensation adjuster license is strongly preferred. Must be eligible to obtain additional licenses as required. Must pass the claims adjuster license exam(s) as assigned within 90 days of being hired. Preference may be shown to candidates with multiple state claims management experience. Experience in workers’ compensation claims practices and laws, court procedures, precedents and state statutes. Ability to use logic and sound reasoning to identify alternative solutions for problem-solving. Strong written and verbal communication skills. Strong analytical skills. Ability to multitasks and manage time effectively and productively. Work effectively independently as well as in a team environment. Develop and maintain strong, effective internal and external relationships. Work effectively in a paperless environment. Skilled in the use of laptops, claims management systems, and other typical business-related programs such as Microsoft Office suite.
