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TPA Claims Specialist III

Alternate Locations:

NY - Rochester (Canal V) - ROC01, NY - Syracuse (Salina) - SY200

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General Description:  Senior Level lost time claim adjuster for workers compensation

 

Responsibilities:

  • Advanced Knowledge of claims function and processes.

  • Ability to effectively communicate with internal and external customers.

    Expert understanding of workers compensation or disability claims management, strategies, resolution techniques and adjusting.

  • Technical/administrative capability to adjust lost time, utilizing the features of the TPA claim management systems.

  • Participates in claim advocacy and negotiations, including claim denials, reserving files, and claim reporting, issuing payments, attending hearings, conciliations or mediations and filing of state forms.

  • Determine compensability of the claim as it relates to the worker compensation jurisdiction.

  • Review and approval of loss time, medical services and expenses to be paid of the claims file.

  • Plan and attend claim reviews with clients, carriers and auditors.

  • Negotiate and recommend claim file settlements to the client.

  • Ability to identify client issues, build a plan towards resolution, execute and manage internal and external expectations effectively.

  • Analyzes claims based on the TPA best practices as outlined in the “Policy and Procedures” manual.

  • Skill set to implement new business with “Special Account Instructions”.

  • Understand the financial impact of losses.

  • Ability to communicate with internal resources to explain results and help develop improvement for risk management plans.

  • Ability to develop high quality output documents for internal resources, clients and carriers

  • Understand client business issues.

  • Attend sales presentations.

  • Act as a team leader with the non lost time claim adjuster and the medical case manager.

 

Knowledge, Skills and Abilities:

·         Ideal candidate will have a minimum of 10 - 15 years of claims administration experience.

·         College degree preferred but high school diploma or graduate equivalent degree required.

·         Expert in MS Office suite of products, especially MS Excel.

·         Superior written and oral communication skills.

·         Ability to lead a team and work well in a team environment.

·         Must have expert analytical thinking and problem-solving skills.

·         Superior organizational skills required.

·         Expert negotiation skills required.

 

 

 

Physical Demands:

Work is performed in a climate controlled office environment with minimal noise and limited to no exposure to chemicals or toxins.  Employees operate office equipment including; telephone - headset, Computer, computer monitors, keyboard, mouse, copier, scanner and mail machine.  Physical tasks of job include; walking, sitting, standing and bending.

 

Analysis of Physical Demands:

  • Constantly (over 66% of time) work performed requires employees to use repetitive hand motions such as typing, using a keyboard, and sitting at a desk.

  • Frequently (34%-66% of time) work performed requires employees to handle and grasp things, walk on normal surfaces, stand and bend.

  • Occasionally (1%-33% of time) work performed requires employees to drive to client appointments, have repetitive foot movements, walk on uneven or slippery surfaces to and from work and occasionally reach outward to grab things and bend.

  • Rarely  (< than 1 hour per week) work performed  requires Lifting/Carrying  items that range from 10-50lbs, pushing/pulling  items that range from 10-50lbs,  twisting/ turning including reaching over shoulder or above head , kneeling or squatting.


Job ID:

17453

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