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Key Risk is looking for an experienced professional who will be provide leadership and technical support to our internal staff and TPA partners to deliver superior results and develop strategies focused on attaining a "World Class" distinction in workers compensation and USLA&H claims handling.
- Manage our TPA partners to assure the quality of the management of claims, service delivery to our clients, reserve accuracy, claim resolution, litigation management, network penetration, jurisdictional compliance and compliance to internal standards.
- Provides direction and technical assistance to internal staff and TPA partners.
- Prepares an annual budget and implements appropriate tracking mechanisms reporting on monthly results and variances.
- Reviews claim files for adherence to company guidelines in the areas of file documentation, reserving practices and reporting.
- Hires, trains and develops an effective staff providing career development and counseling to staff.
- Administers personnel policies and procedures in a fair and equitable manner and in accordance with all applicable corporate and regulatory requirements.
- Monitors critical claim data on a daily/weekly/monthly basis and reports to management on items of importance.
- Conducts regular department/unit/office meetings to inform staff of performance and results and issues effecting company and/or claim operations.
- In conjunction with regional and department staff, develops and communicates department objectives and monitors results on a monthly basis adjusting plans and performance expectations to achieve targeted results.
- Interacts on a regular basis with regional vice presidents, risk management prevention, marketing and underwriting on issues effecting branch or territory operations.
- Handles complaints and inquiries from agents, consumers and various regulatory agencies referring those requiring involvement of others.
- Develops employees through coaching, training, providing ongoing and constructive feedback, and through regular performance and salary reviews.
- Retains staff by managing responsibly and creating a positive work environment.
- Keeps abreast of industry developments, particularly those which impact his or her area(s) of responsibility.
Key Risk is looking for an enthusiastic professional who will be responsible for the management of low exposure workers’ compensation claims. The Claims Associate will be responsible for learning workers compensation laws and providing outstanding service to our clients. This is an entry-level position with no experience necessary.
- Maintain good lines of communication with employers, adjusters, and providers
- Conduct investigation of workers' compensation claims assigned
- Request medical notes, proper billing format, and other written/verbal information from employers and medical providers to determine appropriateness of payment of medical bills and whether a claim is truly medical only
- Discuss with an employee, issues relative to whether a bill has been paid or whether travel or medical reimbursement has been issued
- Timely and accurately reserve for claims assigned
- Document medical notes and relevant written and oral communication received relative to claims in the log notes
- Discuss with an employer, issues relative to an injured workers’ return to work status
- Index images as needed
- Identify potential subrogation claims and notify appropriate supervisor
- Actively work with mentor and supervisor to develop skills to handle all technical aspects of claims, including coverage, disability benefit management, medical management, litigation management, file management, subrogation, reserving and settlement
- Maintain and demonstrate knowledge of the Workers' Compensation Act and Rules and Regulations in jurisdictions assigned
- Immediately notify management of large exposures
Overall Position Summary/Purpose (Briefly describe the job’s primary purpose or contribution to the department or the organization)
Responsible for identifying, researching, and resolving issues in the claims system. Partner with management to communicate recommendations on process and system improvements.
Key Functions/Duties of Position: Describe the overall job responsibilities (including any decision-making authority) for this position.
- Responsible for Claims system performance; troubleshoot errors and create system tickets
- Perform all administrative functions of claims system; create new user profiles, update permissions, etc.
- Provide training, support and guidance to claims staff on system functionality
- Perform weekly regulatory reporting
- Identify and process policy errors and information
- Add and/or update vendors in claims system
- Perform claims system testing and verify data feeds
- Provide support and guidance to inter departments as needed
- Collaborate and work with other Berkley companies in segment to prioritize changes/upgrades to claims system
The Claims Representative is responsible for the analysis and management of workers’ compensation claims for assigned clients, including minor and complex claims. This position will review, investigate, and make decisions regarding coverage, compensability, and appropriateness of claims. The position will process and document claims to ensure compliance with company standards, industry best practices, and legislative provisions. Acts in a fiduciary role on behalf of policyholders and negotiates claim settlements. Claims Representatives conduct the handling of claims in the utmost of good faith in compliance with the rules, regulations and state statutes. The Claims Representative is expected to function with a high degree of competency and independence. The use of sound judgment coupled with strong technical claim handling skills and consistent results are expected.
- Analyzes and processes workers’ compensation claims by investigating and gathering information to determine the exposure on the claim.
- Negotiate settlement of claims up to designated authority level and makes claims payments.
- Calculates and assigns timely appropriate reserves to claims and continues to manage reserve adequacy throughout the life of the claim.
- Calculates and pays benefits due; approves all claim payments; and settles claims within designated authority level.
- Develops and manages claims though well-developed action plans; continues to work the action plan to bring the claim to an appropriate and timely resolution.
- Prepares necessary state filings within statutory limits.
- Actively manages the litigation process; ensures timely and cost-effective claims resolution.
- Coordinates vendor referrals for additional investigation and/or litigation management.
- Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims.
- Frequently communicates with all appropriate parties involved with the claim.
- Maintains professional client relationships.
- Actively executes appropriate claims activities to ensure consistent delivery of quality claims services.
- Keep abreast of all arising workers compensation case law, rules and regulations for our core jurisdictions
- Inform claims organization of case law which impact claims handling or has educational value. Provide synopsis, the case link and how it affects claims department policy and procedures.
- Review claims to ensure appropriate referrals to approved defense counsel.
- Schedule and attend stewardship meetings with defense counsel.
- Manage Defense Council and conduct litigation reviews
- Maintain Defense Counsel Guidelines.
- Assist in the development of a counsel referral method that promotes effective outcomes and minimizes or controls litigation costs.
- Maintain legal contracts.
- Establish and maintain effective working relationships with claims staff, supervisors, providers, and other departments of Key Risk.
- Develop training materials for litigations specialists and claim professionals