VCU Health

The Claims Examiner investigates, and processes Workers' Compensation claims for VCUHS employees.. This job is responsible for handling assigned claims appropriately and in a timely and fair manner, including subrogation of claims and negotiation of settlements with approval of a Claims Examiner Senior or Insurance Services Department AVP/Director.. In addition to or in lieu of Workers' Compensation claims, the Claims Examiner may manage general liability, auto liability or property/casualty claims of low to medium complexity (up to $100,000) and may serve liaison/point of contact for claims adjusters handling commercially insured losses/claims for VCUHS.. Provides regular, professional communications with internal and external stakeholders, including VCUHS employees and their supervisors/managers, VCUHS Employee Health Services, VCUHS Payroll, VCUHS Human Resources, disability benefits vendor (Unum), retained outside counsel, insurance brokers, actuaries, auditors, claims adjusters, attorneys representing VCUHS employees, and the Virginia Workers' Compensation Commission.. Coordinates medical management on workers' compensation claims and acts as a Return-To-Work liaison for VCUHS. Manages low to medium complexity claims.

claims examiner

**This is a hybrid role; 3 days in office, 2 days remote** The Claims Examiner investigates, and processes Workers' Compensation claims for VCUHS 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 that meets the needs of VCUHS. This job is responsible for handling assigned claims appropriately and in a timely and fair manner, including subrogation of claims and negotiation of settlements with approval of a Claims Examiner Senior or Insurance Services Department AVP/Director. This job maintains effective communication with claimants/injured employees, medical staff (treating physicians) and all other internal and external stakeholders as appropriate. This job manages low to medium complexity Workers' Compensation claims with a total dollar value up to $2,000,000. In addition to or in lieu of Workers' Compensation claims, the Claims Examiner may manage general liability, auto liability or property/casualty claims of low to medium complexity (up to $100,000) and may serve liaison/point of contact for claims adjusters handling commercially insured losses/claims for VCUHS. Essential Job Statements Claim Assessment, Administration & Settlement Reviews, investigates, and evaluates all work-related occupational injury claims of low to medium complexity as assigned in a timely and efficient manner. Gathers independent investigative information, interviews relevant witnesses, and takes statements, photos, and measurements as necessary. Preserves evidence. Generates and files timely Employee First Reports of Injury (FROIs) and Subsequent Reports of Injury (SROIs) with the Virginia Workers' Compensation Commission. Ensures compensability determination of all claims assigned, establishes initial and ongoing reserves for medical and lost time claims, and processes payments to medical providers and pay benefits to VCUHS employees in accordance with the Virginia Workers' Compensation Act. Coordinates efforts with VCUHS Employee Health Services and VCUHS Security and Safety Department to investigate claims and identify opportunities to make the work environment safer. Complies with the laws, rules and procedures as outlined in the Virginia Workers' Compensation Act. Evaluates and settles claims as appropriate in consultation with Claims Examiner Senior. Attends trials, depositions and testifies when appropriate. If assigned, reviews, investigates, and evaluates general liability, auto liability or property/casualty claims (including lost/damaged/stolen belongings of patients/visitors and/or valet claims), assesses/apportions the degree of negligence to the parties involved in the claim, and with AVP/Director approval, recommends and/or negotiates appropriate settlements for general liability, auto liability and/or property/casualty claims. If assigned, serves as liaison/point of contact for claims adjusters/Commonwealth of Virginia Division of Risk Management handling commercially insured losses/claims against VCUHS and its controlled/affiliated entities. Medical Management/Return-To-Work Obtains and evaluates past and current medical records to ensure VCUHS pays for appropriate care, accepts responsibility for appropriate body parts (injured), develops and monitors a treatment plan (with the attending physician's assistance) to attain maximum medical improvement. Coordinates 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. Develops and coordinates transitional duty assignments working with multiple-disciplines as necessary to ensure every employee who can work in some capacity has work within VCUHS. Communications and Documentation Provides regular, professional communications with internal and external stakeholders, including VCUHS employees and their supervisors/managers, VCUHS Employee Health Services, VCUHS Payroll, VCUHS Human Resources, disability benefits vendor (Unum), retained outside counsel, insurance brokers, actuaries, auditors, claims adjusters, attorneys representing VCUHS employees, and the Virginia Workers' Compensation Commission. Injured employees are to be treated as valued customers. Litigation & External Vendor Management When needed, properly utilizes the outside services of attorneys, medical management and vocational staff, surveillance staff, and other independent companies needed to provide essential services for claim management. Keeps open lines of communication and ensures that a clearly documented plan that the vendor and claim department execute and all parties follow. Gives clear claim direction to each external vendor. Administrative Support of Insurance Programs Assists 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. Performs other duties as assigned and/or participates in special projects to support the mission of VCUHS. Accepts alternate assignments, as required to fulfill business needs. Patient Population Not applicable to this position. Employment Qualifications Required Education: High school diploma or equivalent. Preferred Education: Associate's or Bachelor's Degree in Business, Finance or closely related field from an accredited program Licensure/Certification Required: N/A Licensure/Certification Preferred: N/A Minimum Qualifications Years and Type of Required Experience Minimum of two (2) years of progressively more responsible Workers' Compensation claims adjudication experience. Previous experience in Microsoft applications. Other Knowledge, Skills and Abilities Required: <ul><li>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.</li><li>Coordinates medical management on workers' compensation claims and acts as a Return-To-Work liaison for VCUHS. Manages low to medium complexity claims.</li><li>Analyzes claims to identify opportunities to improve workplace safety and partners with VCUHS Employee Health, VCUHS Safety and Security Department, injury prevention specialists, and supervisors to address workplace safety concerns.</li><li>May provide oversight to claims assistant and other office personnel.</li></ul> Outside of normal office hours, in the event that an employee sustains a work-related fatality or serious injury requiring hospitalization or an incident causing significant property or casualty damage occurs, if available (reachable by phone or online), it is expected that this job will provide oversight and claim assistance as needed, which may include returning to the affected site and/or coordinating with broker, independent adjuster, claim staff, other VCUHS staff, and/or emergency personnel from a remote location. Cultural Responsiveness Demonstrate a commitment to diversity, equity, and inclusion through continuous development, modeling inclusive behaviors, and proactively managing bias. Other Knowledge, Skills and Abilities Preferred: Previous claim handling experience including general liability, auto liability and/or other property and casualty lines. Previous work experience in risk management or legal setting. Working Conditions General office environment. Physical Requirements Physical Demands: Lifting/ Carrying (0-50 lbs.) Work Position: Sitting Additional Physical Requirements/ Hazards Physical Requirements: Hazards: 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 EEO Employer/Disabled/Protected Veteran/41 CFR 60-1.4.

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