CLAIMS SPECIALIST-WORKERS' COMPENSATION

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. Essential Functions: Required Responsibilities* 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. Job Requirements Education, Work Experience, Certifications** Required: 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 Preferred Associate in Claims (AIC) designation from AICPCU/IIA Essential Competencies and Skills** Required: 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 PowerPoint Proficiency in MS Outlook Preferred Experience in the Workers' Compensation Insurance Industry Experience driving and motivating cross-functional teams to successfully implement strategic or business projects Strong business development skills and knowledge of small business operations Proficiency in Adobe Creative Suite Proficiency in MS Visio Proficiency in MS Access ** To perform this job successfully, an individual must be able to perform each primary responsibility satisfactorily. The requirements listed above are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the primary responsibilities. Supplemental Information Work Leadership Requirements: This position is not a people manager. This position does not have indirect reports. Travel Requirements: Occasional overnight travel (by car or air) Physical Requirements: Be able to withstand typical office work that includes periods of sitting, standing, typing, etc. indoors. In addition to typical office work, must be able to exert up to 10 pounds of force occasionally to move objects. Requires close visual acuity to perform an activity such as preparing and analyzing data and figures, viewing a computer screen, visual inspection, assembly of parts, or extensive reading. Ability to have a flexible work schedule to meet business needs and be at work on-site during specified or core hours. Ability to safely operate a motor vehicle for extended periods, including prolonged sitting, use of hands and feet to operate vehicle controls, and maintaining visual awareness in varying traffic and weather conditions. Must be able to operate standard computer hardware. #J-18808-Ljbffr Gfoat