The Workers’ Empowerment Specialist collaborates with highly trained staff and state-of-the-art technology to promote injured worker recovery in a prompt, fair, and ethical manner. The specialist will possess compassion and humility to serve in the Workers’ Compensation Center of Excellence on the Workers’ Empowerment Team and have a positive impact on injured worker recovery and to the company’s financial success.
- Investigate injuries, establish the facts of the loss to analyze coverage, and determine eligibility for benefits.
- Document claim coverage and compensability for medical only and lost-time claims.
- Meet expectations for initial and subsequent contact with all customers.
- Thoroughly explain benefits and eligibility decisions to the injured worker.
- Respond to all customers in a timely and professional manner.
- Collaborate with team members, if needed, to exceed the expectations of our customer experience.
- Assist with training/mentoring of Workers’ Empowerment Specialists.
- Assist management when required with projects or leadership as requested.
- Handle the various duties/responsibilities of the Assistant Workers’ Empowerment Leader/Workers’ Empowerment Leader as delegated in their absence.
Investigation & Medical and Disability Management
- Verify facts of loss with multiple parties and identify relevant sources of information related to the injured worker and claim.
- Recognize potential insurance fraud and refer those files to our Special Investigation Unit.
- Evaluate the exposure and establish the appropriate level of handling.
- Manage the injured workers’ medical treatment, recovery, and return to work against ongoing disability guidelines and projected target dates.
- Manage disability and return to work with the injured worker, employer, and provider.
- Analyze medical records to proactively manage medical treatment for optimal recovery outcomes.
- Evaluate medical information for timely approval of the causally related treatment.
- Assess medical bills for accurate authorization and timely payment.
- Clearly document the claim file and properly document file material electronically.
- Exercise diary system and target dates to move files to closure.
- Organize and plan a workload of varying complexity to improve injured worker experience.
- Strategic use of nurse case management, when appropriate.
- Appropriate use of authorized strategic partners.
- Properly identify applicable statutory benefit jurisdiction and accurately calculate benefits, disability, and settlements as outlined by the rules and regulations of the state.
- Identify cases for settlement. Evaluate claims and request authority no later than 30 days prior to mediation date and negotiate a settlement.
- Evaluate and negotiate liens.
- Maintain closing ratio as dictated by the management team.
- Ability to attend conferences, client meetings, mentor other adjusters and assist management as requested.
- All file handling must be within state statutes, NARS Best Practices, Workers’ Compensation Center of Excellence Claim Handling Guidelines, and account servicing instructions.
- Other duties as assigned, which may require travel.
- Investigate claims to determine if negligent actions of a third party contributed to the work injury.
- Refer all files with subrogation potential to the subrogation department or as directed by the client.
- Report on potential recovery options that may be viable in the claim.
- Effectively communicate the importance of retraining evidence and impact on potential recovery to the client.
- Develop and direct a litigation plan with a defense attorney (if assigned), utilizing all defenses and tools to bring the file to closure.
- Ensure all filings and state-mandated forms are completed timely.
- Litigated files must be handled on a diary based on current activity, but no greater than every 60 days.
- Review claim files involving active litigation on a monthly basis at minimum, and document responses to filings, development of defenses, depositions, and timely referral to defense counsel.
- Collaborate and agree to specific direction with defense counsel on litigated files.
- Attend mediations and trials as required for cost-effective litigation management.
- Establish reserves (anticipated cost to bring the file to close based on known facts) as soon as practical and manage to adjust at the time of any exposure changing event.
- Report all reserve changes timely.
- Pay all known benefits, ensuring they are paid timely according to state statute.
- Verify all provider bills and strategic partnership invoices have been appropriately reviewed and paid within standard timeframes.
Reporting Requirements & Compliance:
- Report all serious injuries and potential large loss claims to the client and/or reinsurer based upon the criteria provided by the client.
- Must pass all internal and external audits, which include those performed by regulatory agencies, carriers, and clients.
- Follow reporting requests as outlined by client account servicing instructions and Workers’ Compensation Center of Excellence Claims Handling Guidelines.
Education / Licensing:
- High School Diploma or equivalent required, 2-year degree or higher preferred.
- 2 to 7 years of prior claim adjusting experience or be a graduate of the NARS developmental adjuster program.
- Must be eligible for reserve/payment authority level of $25,000+ when appropriate.
- Must be open to handling multiple jurisdictions and obtain appropriate licensing as needed.
- Must be able to use active listening skills to understand others’ thoughts and emotions.
- Demonstrate empathy and compassion for enhanced injured worker experience.
- Possess the interpersonal skills to handle sensitive and confidential situations and information.
- Requires organization and time management skills.
- Requires ability to negotiate claims and to direct litigation.
- Requires ability to work independently but at the same work collaboratively with others.
- Must be able to analyze data and information to make considered decisions.
- Must speak and write using clear, concise, and appropriate language.
- Communicate openly and honestly with colleagues and customers.
- Ability to take personal responsibility for the quality and content of your work.
- Requires long periods of sitting.
- Requires working indoors in environmentally controlled conditions.
- Requires lifting of files and boxes up to approximately 20 pounds.
- Repeated use of a keyboard, mouse, and exposure to computer screens.
- Requires travel as assigned, which can at times be extensive (5 to 7 days per month).