Workers Compensation Return to Work Claim Professional - Cleveland OH

Job Description Salary: $67,000.00 - $110,600.00 Location: Cleveland, Ohio Openings: 1 Opportunity Manage Workers' Compensation claims with lost time to conclusion and negotiate settlements where appropriate to resolve claims. Coordinate medical and indemnity position of the claim with a Medical Case Manager. Independently handles assigned claims of low to moderate complexity where wage loss and the expectation is a return to work to modified or full duty or obtain MMI with no RTW. There are no litigated issues or minor to moderate litigated issues. The claim may involve minor sprains/ minor to moderate surgery. The injured worker is working modified duty and receiving ongoing medical treatment. The injured worker as returned to work, reached Maximum Medical Improvement (MMI) and is receiving PPD benefits. File will close as soon as the PPD is paid out. With close to moderate supervision, may handle claims of greater complexity where injured worker remains out of work and unlikely to return to position. Employer is unable to accommodate the restrictions. The claim involves moderate to complex litigation issues. Injured worker has returned to work, reached MMI, and has PPD. File litigated to dispute the permanency rating and/or causality. Injured worker has been released to work with permanent restrictions and there has been a change in the current position. Injured worker is receiving Vocational Rehabilitation. Claims that have been reopened for additional medical treatment on more complex files. Injuries may involve one or multiple back, shoulder or knee surgeries, knee replacements, claims involving moderate to complex offsets, permanent restrictions and/or fatalities. Claims on which a settlement should be considered. Responsibilities Conduct investigations, including, but not limited to assessing policy coverage, contacting insureds, injured workers, medical providers, and other parties in a timely manner to determine compensability. Establish and update reserves to reflect claim exposure and document rationale. Identify and set actuarial reserves. Apply knowledge to determine causal relatedness of medical conditions. Manage files with an emphasis on file quality, including timely contact, proper documentation and proactive resolution of outstanding issues. Achieve a positive end result by returning the injured party to work and coordinating the appropriate medical treatment in collaboration with internal nurse resources where appropriate. Work in collaboration with specialty resources (medical and legal) to proactively pursue claim resolution opportunities (return to work, structured settlement, and discontinuation of benefits through litigation). Develop strategies to manage losses involving statutory benefit entitlement, medical diagnoses, Medicare Set Aside to achieve resolution through the best possible outcome. Collaborate with our internal nurse resources (Medical Case Manager) to integrate the delivery of medical services into the overall claim strategy. Prepare necessary letters and state filings within statutory limits. Pursue all offset opportunities, including apportionment, contribution and subrogation. Evaluate claims for potential fraud. Proactively manage inventory with documented plans of action to ensure timely and appropriate file closing or reassignment. Effectively manage litigation to drive files to an optimal outcome, including resolution of benefits. Understand and apply Medicare Set Asides and allocations. Negotiate settlement of claims within designated authority. May use structured settlement/annuity as appropriate for the jurisdiction. In order to perform the essential functions of this job, acquisition and maintenance of Insurance License(s) may be required to comply with state and company requirements. License(s) must be obtained within three months of starting and ongoing continuing education credits as mandated. Perform other duties as assigned. Qualifications Minimum 2 years Workers Compensation claim handling experience. Analytical Thinking: Identifies current or future problems or opportunities; analyzes, synthesizes and compares information to understand issues; identifies cause/effect relationships; and explores alternative solutions that support sound decision-making. Communication: Expresses, summarizes and records thoughts clearly and concisely orally and in writing by applying proper content, format, sentence structure, grammar, language and terminology. Ability to effectively present file resolution to internal and/or external stakeholders. Negotiation: Intermediate ability to understand alternatives, influence stakeholders and reach a fair agreement through discussion and compromise. General Insurance Contract Knowledge: Interprets policies and contracts, applies loss facts to policy conditions, and determines whether a loss comes within the scope of the insurance contract. Principles of Investigation: Intermediate investigative skills, including ability to take statements and follow a logical sequence of inquiry with a goal of arriving at an accurate reconstruction of events related to the loss. Value Determination: Intermediate ability to determine liability and assign a dollar value based on damages claimed and estimates, and sets and readjusts reserves. Settlement Techniques: Intermediate ability to assess how a claim will be settled, when and when not to make an offer, and what should be included in the settlement offer package. Legal Knowledge: General knowledge, understanding and application of state, federal and regulatory laws and statutes, rules of evidence, chain of custody, trial preparation and discovery, court proceedings and other regulations applicable to the insurance industry. Medical Knowledge: Intermediate knowledge of the nature and extent of injuries, periods of disability, and treatment needed. WC Technical: Intermediate ability to demonstrate understanding of WC products and apply available resources and technology to resolve claims. Work within jurisdictional parameters of the assigned state. Customer Service: Advanced ability to build and maintain productive relationships with insureds and deliver results with optimal outcomes. Teamwork: Advanced ability to work together when actions are interdependent and the team is mutually responsible to produce a result. Planning & Organizing: Advanced ability to establish a plan/course of action and contingencies for self or others to meet current or future goals. Maintain continuing education requirements as required or as mandated by state regulations. Required Education & Experience High School Diploma or GED. 1 year Workers Compensation claim handling experience or successful completion of the WC trainee program. License Requirements May require acquisition and maintenance of an Insurance License within three months of starting and ongoing continuing education credits as mandated by state and the employer. Additional Information Affiliate Sponsor: Travelers Insurance #J-18808-Ljbffr VetJobs