Claims Specialist

Description

This position is responsible for investigating and managing Workers' Compensation claims to ensure accurate and timely benefit administration while safeguarding Members' pooled funds. It involves assessing claim compensability, coordinating medical treatment, and facilitating claim resolution in compliance with Texas Workers' Compensation regulations. This position also requires effective communication with injured workers, medical providers, and fund members to support fair and efficient claims handling.

This position is responsible for investigating and managing Workers' Compensation claims to ensure accurate and timely benefit administration while safeguarding Members' pooled funds. It involves assessing claim compensability, coordinating medical treatment, and facilitating claim resolution in compliance with Texas Workers' Compensation regulations. This position also requires effective communication with injured workers, medical providers, and fund members to support fair and efficient claims handling.

• Conducts thorough investigations of Workers' Compensation claims to determine compensability, including interviews with Members, claimants, and witnesses, and reviews medical reports, personnel files, and other relevant documents.
• Calculates and administers indemnity benefits, including Temporary Income Benefits (TIB), Impairment Income Benefits (IIB), Supplemental Income Benefits (SIB), Death Benefits (DB), Lifetime Income Benefits (LIB), multiple employment, adjusted benefits, and benefits checks with multiple payees in accordance with the Texas Workers' Compensation rules.
• Maintains and manages claims to conclusion by coordinating with Members, medical providers, preauthorization, and injured workers to drive claims towards resolution. Effectively document the claim file per the Pool’s Service Level Objectives.
• Coordinates with vendors for the management of Peer Reviews, Designated Doctor (DD) exams, and Post-DD Required Medical Examinations. Ensure compliance with doctor's orders, medical instructions, and the Texas Labor Code.
• Prepares cases for dispute resolution and participates in hearings and dockets to support claim resolution.
• Handles incoming communications, including phone calls and emails, and ensures the accuracy of documents received from fund members, requesting corrections when necessary. Shares responsibility for the emergency after-hours line.
• Assists in training and educating Members on Workers’ Compensation processes and procedures.
• Conducts periodic eligibility checks on beneficiaries to verify continued qualification for benefits.
• Submits required documentation to the Division of Workers' Compensation within mandated deadlines.
• Reviews and processes incoming documents, including legal and expense invoices, medical bill payments, travel reimbursements, and work status reports, while maintaining organized and properly labeled claim files.
• The above responsibilities are intended to describe the general nature and level of work being performed by individuals assigned to this job. They are not intended to be an exhaustive list of all responsibilities, duties and skills required by the position. All employees may have other duties assigned at any time.

• B.A. or B.S. degree in Business, Insurance, Risk Management, or related field
• Years of
  
  Experience:
  
  3
• Area of
  
  Experience:
  
  Workers’ Compensation
• Texas Department of Insurance All Lines or Workers’ Compensation Adjuster License

Equivalent combinations of education and experience will be accepted

• Associate in Claims (AIC) designation from AICPCU/IIA

• Valid Texas driver’s license and a good driving record
• Possess knowledge and understanding of relevant laws, rules, and regulations
• Excellent decision-making and problem-solving skills
• Excellent oral and written skills
• Proficiency in MS Excel
• Proficiency in MS Word
• Proficiency in MS Power Point
• Proficiency in MS Outlook

• Experience in the Workers’ Compensation Insurance Industry
• Experience driving and motivating…