Job Title: Senior Claims Examiner
Location: Richmond, VA
Duration: 4+ Months (Possibility Of Extension)
Work Arrangement: Onsite (General Office Environment) Monday - Friday 8am – 4:30pm
 
Position Summary
The Claims Examiner Senior investigates and processes Workers’ Compensation claims for CLIENT'S employees. This job assists in the coordination of an effective commercial insurance and self-insured Workers’ Compensation Claim Program that is compliant with state laws and meets the needs of CLIENTS. This job is responsible for handling assigned claims appropriately and in a timely and fair manner. This job manages subrogation of claims and negotiates settlements. This job maintains effective communication with claimants/injured employees, medical staff (treating physicians), employee supervisors, outside counsel, and all other internal and external stakeholders as appropriate. This job manages high complexity Workers’ Compensation claims with a total dollar value in excess of $2 million. This job must fully understand and comply with Virginia Workers’ Compensation laws. In addition to or in lieu of Workers’ Compensation claims, the Claims Examiner Senior may manage general liability, auto liability or property/casualty claims from low to high complexity and may serve liaison/point of contact for claims adjusters handling commercially insured losses/claims for CLIENTS.
 
Essential Duties & Responsibilities
Performance Expectation: Claim Assessment, Administration & Settlement

• Review, investigate, and evaluate all work-related occupational injury claims as assigned in a timely and efficient manner.
• Gather independent investigative information, interview relevant witnesses, and take statements, photos, and measurements as necessary.
• Preserve evidence.
• Generate and file timely Employee First Report of Injury (FROIs) and Supplement Reports of Injury (SROIs) with the Virginia Workers Compensation Commission.
• Ensure compensability determination of all claims assigned.
• Establish initial and ongoing reserves for medical and lost time claims.
• Process payments to medical providers and pay benefits to CLIENTS employees in accordance with the Virginia Workers’ Compensation Act.
• Coordinate efforts with CLIENTS Employee Health Services and CLIENTS Security and Safety Department to investigate claims and identify opportunities to make the work environment safer.
• Comply with the law, rules and procedures as outlined in the Virginia Workers’ Compensation Act.
• Evaluate and settle claims as appropriate, consulting with the AVP/Director as needed.
• Attend trials, depositions and testify when appropriate.
• If assigned, review, investigate and evaluate general liability, auto liability or property/casualty claims from low to high complexity (including lost/damaged/stolen belongings of patients/visitors and/or valet claims).
• Assess/apportion the degree of negligence to the parties involved in the claim.
• Research applicable case law.
• With AVP/Director approval, recommend and/or negotiate appropriate settlements for general liability, auto liability and/or property/casualty claims.
• If assigned, serve as liaison/point of contact for claims adjusters/Commonwealth of Virginia Division of Risk Management handling commercially insured losses/claims against CLIENTS and its controlled/affiliated entities.

 
Medical Management, Return-To-Work

• Obtain and evaluate past and current medical records to ensure CLIENTS pays for appropriate care.
• Accept responsibility for appropriate body parts (injured) and develop and monitor a treatment plan (with the attending physician’s assistance) to attain maximum medical improvement.
• Coordinate with the attending physician to develop and document an effective plan to help the injured employee back to transitional duty as soon as appropriate and/or a release to full duty.
• Develop and coordinate transitional duty assignments working with multiple disciplines as necessary to ensure every employee who can work in some capacity has employment within CLIENTS.
• May process complex lifetime medical and/or defined period medical claims.

 
Communications and Documentation

• Provide regular, professional communications with internal and external stakeholders, including CLIENTS employees and their supervisors/managers, CLIENTS Employee Health Services, CLIENTS Payroll, CLIENTS Human Resources, disability benefits vendor (Unum), retained outside counsel, insurance brokers, actuaries, auditors, claims adjusters, attorneys representing CLIENTS employees, and the Virginia Workers’ Compensation Commission.
• In particular, injured employees are to be treated as valued customers.
• Thoroughly and accurately document ongoing facts and relevant information necessary for establishing compensability, liability, the use of vendors, medical, expense and indemnity payments, and what is being done to move claims toward closure.

 
Litigation & External Vendor Management

• Provide litigation and vendor management.
• When needed, properly utilize the outside services of attorneys, medical management and vocational staff, surveillance staff and other independent companies to provide essential services for claim management.
• Keep open lines of communication and ensure that a clearly documented plan that the vendor and claim department execute and all parties follow.
• Give clear claim direction to each external vendor.

 
Administrative Support of Insurance Programs

• Assist with any other claim activity as directed by the Department AVP/Director, including negotiation of Workers’ Compensation bills on non-employee claims and assisting in risk assessments, annual self-insurer surveys, OSHA filings, Bureau of Labor Statistics surveys, and annual insurance renewal process.
• Demonstrate personal ownership and accountability for safety across the area of responsibility by role modeling daily key concepts of a high reliability organization as personal work habits.
• Ensure responsibility and visible commitment of diversity equity and inclusion strategy, programs, and initiatives through collaboration and implementation of initiatives across the health system.
• Perform other duties as assigned and/or participate in special projects in order to support the mission of CLIENTS.
• Accept alternate assignments, as required to fulfill business needs.

 
Required Qualifications

• High school diploma or equivalent.
• Minimum of seven (7) or more years of progressively more responsible Workers’ Compensation claims adjudication or equivalent claims handling experience.
• Previous experience with Microsoft Office applications.
• Previous negotiations skills required.
• Determines acceptance and/or compensability of claims, including the investigation, evaluation, and settlement of claims, establishes reasonable reserves, authorizes payments within authority, and develops recommendations to the Director and senior management.
• Successfully performs medical management on workers’ compensation claims and acts as a Return-To-Work liaison for CLIENTS.
• Manages litigation and high complexity claims.
• Analyzes claims to identify opportunities to improve workplace safety and partners with CLIENTS Employee Health, CLIENTS Safety and Security Department, injury prevention specialists, and supervisors to address workplace safety concerns.
• Demonstrate a commitment to diversity, equity, and inclusion through continuous development, modeling inclusive behaviors, and proactively managing bias.

 
Preferred Qualifications

• Associate’s or Bachelor’s Degree in Business, Finance or closely related field from an accredited program.
• Previous lead or supervisory experience.
• Claim handling experience including general liability, auto liability and/or other property and casualty lines.
• Previous work experience in risk management or legal setting.

 
Physical Requirements

• Physical Demands: Lifting/Carrying (0-50 lbs.).
• Work Position: Sitting.
• Mental/Sensory – Emotional:
• Mental/Sensory: Strong Recall, Reasoning, Problem Solving, Hearing, Speak Clearly, Write Legibly, Reading, Logical Thinking.
• Emotional: Steady Pace, Able to Handle Multiple Priorities, Frequent and Intense Customer Interactions, Able to Adapt to Frequent Change.

 
 
At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $ 38.96/hr.