Handles medical only workers’ compensation claims. Investigates and determines compensability, checks coverage, establishes and maintains reserves, handles related correspondence and reports and maintains records. Reviews claim files on a regular basis and takes necessary follow up and/or closing action.
Establishes imediate contact with policyholders, claimants and medical providers. Contacts Agents as necessary.
Evaluates and resolves coverage questions, exercising discretion and independent judgement and in compliance with applicable workers’ compensation law.
Receives, processes and takes appropriate action on claim-related communications, including bills, medical reports, specialist investigative reports and telephone calls. Determines claims to be paid, compromised.
Refers claim to WC Adjuster when nurse case management appears appropriate and in cases of suspected fraud.
Participates in informal presentations to Agents and Policyholders.
Assigns, monitors and controls activities of vendors in cost-effective manner.
Attends industry-related training programs to stay current on legal developments and ensure compliance with applicable laws and regulations impacting the operation of the department.