JOB SUMMARY:

At the direction of the Claims Supervisor, Claims Manager, investigates, evaluates, disposes and settles moderately complex to complex/high exposure claims. Includes the investigation, evaluation and determination of coverage, compensability and responsibility and the setting of proper reserves. You will be working with the Alternative Dispute Resolution Program (ADR) which encompasses mostly City of Fresno Police Officers. However, you will also be working with other employees of the Fresno Police Department.

 

This position requires considerable interaction with the City of Fresno, claimants, providers, claims examiners, ADR ombudsperson and other Tristar staff. Therefore, consistently being at work in the office or home office location as applicable, in a timely manner, is inherently required of this position.

 

 

 DUTIES AND RESPONSIBILITIES:

Processes moderately complex to complex or high exposure claims consistent with clients’ and corporate policies, procedures and “Best Practices” and in accordance with any statutory, regulatory and ethics requirements. Independently analyzes claim exposure, determines a proper plan of action to appropriately mitigate and settle/close the claim working within established level of authority. Interacts with injured workers, client contacts and attending Physician(s) to ensure awareness and understanding of the Workers’ Compensation process, requirements and entitlements. Interacts with disability and leave examiners’ for coordination of non occupational benefits. Prepares and issues notices in accordance with mandated requirements and regularly reviews and stays abreast of applicable laws, rules and regulations that may impact how claims are processed. Establishes and maintains proper reserving throughout the life of the claim. Identify subrogation potential and pursue the process for reimbursement. Complies with carrier excess reporting and threshold requirements. Coordinates medical treatment for injured workers and provides information to treating physician(s) regarding the employee’s medical history, health issues and job requirements. Fully understands Medicare reporting requirements as they relate to a Workers’ Compensation claim. Facilitates early RTW through temporary, transitional, alternate, or modified work. Manages all medical aspects of a claim file with a focus on RTW and end of treatment. Refers appropriate files for task management assignments to approved vendors for medical management, special investigative needs, conditional payments, etc. up to assigned authority. Monitors status and quality of work performed. Serves as a liaison between medical providers, employees, legal professionals, clients and vendors. Independently manages claims in litigation with regular and consistent communication with defense counsel to make recommendations and develop strategy. Enters and maintains accurate information in the claims management computer system. Clearly communicates concise action plans and present plans for moving the claim to resolution. Meets with clients to discuss on-going claims or review open claim inventory. Effectively controls expenses on all Workers’ Compensation claims. Mentors first level WC Examiners. All other duties as assigned.

 

EQUIPMENT OPERATED/USED:  Computer, fax machine, copier, printer and other office equipment.

 

SPECIAL EQUIPMENT OR CLOTHING:  Appropriate office attire.

QUALIFICATIONS REQUIRED:

 

Education: High School Diploma or GED required: Bachelor’s degree in related field (strongly preferred) or equivalent combination of education and experience. 

 

Experience: Three (3) to five (5) years of Workers’ Compensation Claims administration experience required working with self-insured and/or insured claims.

Preferred Skills:

Demonstrated experience working with complex, high exposure and litigated WC claims. Appropriately licensed and/or certified in all States in which claims are being handled. Multi-Jurisdiction experience is a (+). Bilingual Spanish is a (+) Able to work in a fast paced, high stress, changing environment. Strong analytical, critical thinking and problem solving skills required. Effective verbal and written communication skills required. Excellent planning, organizing and negotiation skills required. Attention to detail. Negotiation and interpretive skills necessary. Demonstrated knowledge of established claims strategy and mitigation techniques. Establishes and maintains effective working relationships with those contacted in the course of work. Proficiency with computers and technology – working knowledge of Microsoft Office application suite (MS Word, Excel, etc. and familiarity and experience using standard claims administration applications. Good interpersonal skills with an ability to work within a team environment. Able to effectively handle multiple priorities simultaneously. Works independently.