Claims Examiner II / Claims Adjuster - Workers' Compensation
Montana State Fund
August 14, 2018
$52,600 - $72,270/yr
Full Time - Entry Level
Do you enjoy having work-life balance in a collaborative team-oriented culture that celebrates your success? Do you have 2 years of workers’ compensation indemnity work experience?
If this sounds like you, come put your experience and skill set to work as a Claims Examiner II at Montana State Fund!
Montana State Fund is looking for a Workers’ Compensation Claims Examiner II to join the Claims Operations team. The ideal candidate has a passion for providing a best in class customer experience by helping injured employees and the policyholders. The successful candidate will get to be a part of a collective team that performs a variety of claims management activities, including investigate, evaluate, negotiate and settle claims by utilizing Montana State Fund Claim Guidelines and Industry Best Practices. The ideal candidate thrives in daily client interaction as well as utilizing their effective written and verbal communication skills. The successful candidate should enjoy a dynamic, fast-paced environment where they are able to put their investigation and negotiation skills to work. Strong Montana workers’ compensation knowledge will also be a plus.
If this sounds interesting to you, please read on to learn about the essential functions, duties, and minimum qualifications for the Workers' Compensation Claims Examiner II position.
Manage assigned caseload of indemnity and medical only claims of reported injury or occupational disease with a moderate level of reserve and settlement authority and under limited supervision/mentoring.
Investigates, evaluates, negotiates and settles claims in accordance with Montana State Fund Claim Guidelines and industry Best Claim Practices. Calculates and authorizes payment of medical and wage loss benefits. Assigns, directs and monitors rehabilitation and medical case management activities in accordance with the Claim Guidelines and industry Best Claim Practices. Runs reports as needed to document medical, pharmacy and indemnity expenditures on claims. (65%)
Identifies and performs claims management activities to mitigate negative trending and/or meet team needs with regard to claim and/or account management including service as a team representative to industry groups. (20%)
Participate in companywide projects both on a voluntary basis and as requested. (10%)
Participate in large loss and catastrophic claim meetings to review, advise, and develop plans of action, review reserve adequacy, and to recommend resources needed to address key claim issues. (5%)
Investigates, evaluates, negotiates, and resolves assigned claims in accordance with the MSF Claim Guidelines and industry Best Claim Practices
Calculates and authorizes payment of medical and indemnity benefits within limits of authority and according to Montana Code Annotated (MCA) and fee schedules.
Appropriately handles policyholder and injured worker confidential information according to MSF policies.
Manage diary and complete activities and tasks to ensure that claims move to the best outcome and timely resolution.
Demonstrate ability to successfully manage vendors in course of claim management.
Analyze liability issues and determine exposure to properly set claim reserves.
Obtain all necessary and pertinent claim file documents to achieve thorough work file documentation.
For all assigned claims, and within timeframes outlined in the MSF Claim Guideline and industry Best Claim Practices, identify, document and implement the claim strategy and steps to achieve resolution of each assigned claim.
Demonstrate consistent sound decision-making for all aspects of claim handling including reserve and settlement decisions.
Coordinate the assignment and management of expert resources to assist in case resolution. Includes, but not limited to, peer review, legal resources, nurse case management, vocational rehab, designation of primary care provider, and/or other appropriate resources.
Thoroughly investigate, evaluate, & present findings on potential catastrophic claims.
Prepare annual reserve updates and a plan of action for all assigned claims including presentation of same to designated claim experts on all catastrophic and large loss claims.
Continuously seek and accept claim management feedback in support of in the MSF Claim Guidelines and industry Best Claim Practices.
Attend, participate, and demonstrate understanding and application of training on applicable Montana Workers’ Compensation statutes and Montana Code annotated, case law, as well as in the MSF Claim Guidelines, systems, and policies and industry Best Claim Practices.
Establish and maintain productive relationships with assigned accounts. Manage customer relations and coordinate additional support when escalation requires such.
Respond to injured worker and policyholder inquiries, adequately explain the workers’ compensation claim process in lay terms, and assist the injured worker and policyholder to understand the claim handling process throughout the life of the claim.
Demonstrate professional business communications and behaviors, and customer service skills with internal and external customers.
Develop and maintain positive working relationships with injured worker attorneys, medical providers and vendors.
The Duties Below are in Addition to Those Required of a CE I
Provide claim expertise and policy oversight to lower level claim examiners and peers as requested.
Present feedback and strategic recommendations in a positive manner.
Identify policyholder claim trends and/or issues.
Perform activities to mitigate negative claim trending and/or meet policyholder needs with regard to claim and/or policy management.
Attend mediations, depositions, and court appearances, and assist in development of mediation and litigation management as needed for own claims as well as assisting lower level examiners.
Participate in assigned companywide project/tasks/initiatives as assigned with emphasis on team and organizational goals/results.
Is able to run and utilize position specific reports.
Provides coaching and mentoring to Claim Examiner Trainees and other Claims Examiners either as part of formal or informal mentoring relationship as requested by their Claims Manager.
Minimum Requirements of the Position
Bachelor’s Degree with two (2) years of workers’ compensation indemnity work experience,
High School education or GED plus six (6) years of workers compensation indemnity work experience.
Relevant designations and certifications.
Internal Number: 20033
About Montana State Fund
Welcome to a place where your life is as important as your job.
Our people have something many workers don't. A life.
Competitive salary and benefits are only half the story. The other half is about you and your decision to live and work in Montana. At Montana State Fund, you'll find that our people appreciate their surroundings. They live a balanced life, by working hard and enjoying their beautiful home state. It shows in the quality of their work - and the smiles on their faces.
We are a dynamic company dedicated to the professional and personal growth of our employees through challenging work, progressive career advancement, education reimbursement and a wide range of training and professional development programs. Best of all, we're located in the heart of the Big Sky Country where you'll find a quality of life unlike any other.
Montana State Fund works hard to retain great talent by offering a comprehensive benefit package and then some. In fact, benefits include higher education reimbursement, plus training and development programs. In addition, you can set up special medical expense accounts for tax-free income, much like a flex plan.
W...e offer positions in a wide variety of professions, each with the challenge and upward mobility your career needs. With so many careers to choose from, one is sure to fit.