Senior Claims Analyst - Workers' Compensation
Location: Pittsburgh Pennsylvania
Description: Highmark is hiring Senior Claims Analyst - Workers' Compensation right now, this job will be placed in Pennsylvania. More complete informations about this job opportunity please give attention to these descriptions. General Overview:
This position is responsible for administering Workers' Compensation claims pursuant to department guidelines, individual client expectations and the statutory provisions of the Workers' Compensation Act. The incumbent must investigate claims using tools such as the Employer Interview, Claimant Interview, Claimant Questionnaire, ISO Claim Indexing, pursuit of prior medical records and disability case management to assist in the decision making process. The incumbent must determine compensability of claims, i! .e. whether to accept or deny liability, based on the outcome ! of the investigation. The incumbent must develop action plans to address strategy for claim resolution. The incumbent must manage claim outcomes for early return to modified and regular duty work, conclusion of medical treatment and ultimate closure. The incumbent is responsible for establishing and adjusting reserves to accurately reflect financial exposure. The incumbent interfaces with clients and maintains relationships.
Essential Responsibilities:
1. Communicate effectively with internal and external customers during the investigation, adjudication, and resolution of claims.
- External customers include insured employers (policyholders), injured workers, medical providers, treating physicians, medical case managers, brokers, attorneys and reinsurers.
- Internal customers include Claims Analysts, Bill Processors, Account Managers, Loss Control Consultants, Underwriters, Sales Reps and Claim Intake personnel.
- Investigate claims by interviewing employer contacts, claimants and, in more complex cases, witnesses; research prior claims through ISO Claim Indexing; and pursue prior medical records if warranted based on the particulars of the claim.
- Monitor medical case management in an effort to obtain medical opinions on prior medical records and to assist in evaluating the alleged mechanism of injury and its relatedness to the report physical complaints.
- Determine compensability, i.e., whether to accept or deny liability, by compiling, assessing and making critical decisions regarding all information obtained during the investigation of the claim.
- Obtain confidential payroll information, calculate benefits and issue indemnity payments to claimant! s.
- Develop detailed action plans to address strategy and manag! e claim outcomes for early return work, conclusion of medical treatment and claim resolution resulting in controlled losses.
- Initiate fraud referrals and surveillance investigations and monitor feedback for impact on claim resolution.
- Closely monitor claim developments and revise established action plan to adjust strategies in response to critical medical, legal and return-to-work developments.
- Carefully follow medical case management assignments and provide direction to Case Managers to ensure aggressive pursuit of medical updates and return to work strategies. Utilize feedback to determine and initiate proactive steps to expedite return to pre-injury status and conclusion of medical treatment.
- Manage claim outcomes for early return to modified and ! regular duty, conclusion of medical treatment and closure.
- Evaluate and adjust reserves to accurately reflect financial liability.
- Refer claims for legal intervention and other outside service vendors as needed to manage outcomes.
- Coordinate and manage defense counsel efforts to ensure that litigated claims are appropriately resolved and financial liability mitigated. Conduct legal claim reviews throughout the year with preferred counsel.
- Report claims to reinsurance broker in accordance with reinsurance treaties and issue follow-up reports every 6 months.
- Negotiate settlement of claims up to designated authority level.
- Conduct quarterly claim review meetings with employers and brokers
- Approve or deny provider bills accordingly with 100% compliance to regulatory requirements.
- Recognize adverse utilization trends and file Utilization Reviews with the PA Bureau of Workers' Compensation to question the reasonableness and necessity of medical treatment.
- Employer's First Report of Occupational Injury or Disease
- Notice of Compensation Payable, Notice of Temporary Compensation Payable or Agreement for Compensation
- Notice of Workers' Compensation Denial
- Notice of Ability to Return to Work
- Notice of Suspension
- Supplemental Agreement
- Final Receipt
- Statement of Account
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- The incumbent is responsible for resolving inquiries for customers, both internal and external. The incumbent must reply to written or telephonic inquiries in a prompt, courteous, professional and informative manner.
- Inquiries encompass numerous contacts and originate from various sources such as injured workers, employers, brokers, providers, attorneys and physicians.
- Incumbent is responsible for initiating and maintaining ongoing communication with employer representatives who may range from HR representatives to senior management.
- High School diploma or GED
- A minimum of 5 years of prior workers compensation lost time claims experience
- Bachelor's degree
- .
If you were eligible to this job, please email us your resume, with ! salary requirements and a resume to Highmark.
If you inter! ested on this job just click on the Apply button, you will be redirected to the official website
This job starts available on: Thu, 13 Feb 2014 18:26:17 GMT
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