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The claim involves moderate to complex litigation issues IW has returned to work, reached Maximum Medical Improvement (MMI), and has PPD. File litigated to dispute the permanency rating and/or causality.
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Form a partnership with the medical case manager to maximize early return to work potential thereby reducing the need for extended disability payments, vocational rehabilitation, and other protracted claims costs.
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Requires a working knowledge of the Labor Code of the State of California as it pertains to workers compensation claims and the legal requirements for handling them. Requires a high degree of claims handling expertise to include a minimum of at least five years experience managing indemnity cases, many with complex or high potential subrogation, rehabilitation, medical management, and/or legal issues & possess an SIP certificate.
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Initiate the referral to the SIU of cases with suspected fraud. Review all medical bills for appropriateness prior to referral to InterMed for payment and posting to the claim file.
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Thoroughly and accurately document ongoing case facts and relevant information necessary for establishing compensability, the need for disability payments, the use of vendors, medical and expense payments, and what is being done to move the case toward closure.
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Reports directly to the unit Claims Supervisor and may be called upon to provide technical backup in the absence of the Claims Supervisor. In accordance with applicable statutes and in keeping with company rules, regulations, and established performance objectives, is responsible for effectively managing to conclusion an assigned inventory of claim files that may include cases of extreme complexity or with unique or unusual issues.
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Independently handles assigned claims of low to moderate complexity where Wage loss and the expectation is a return to work to modified or full duty or obtain MMI with no RTW. There are no litigated issues or minor to moderate litigated issues.
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Coordinates case management with the Company's workers' compensation and disability vendor to monitor claim processing and support the employee's return to work.
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The associate will work closely with Loss Control to return claimants to work and will notify Loss Control immediately if a policyholder is uncooperative in return-to-work efforts (Workers Compensation Representatives only.
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Proactively manage the technical aspects of complex and high severity medical and CAT claims for quality outcomes and return to work opportunities under the regular guidance of Complex Claims Supervisor.
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Manage Workers' Compensation claims with lost time to conclusion and negotiate settlements where appropriate to resolve claims. Work in collaboration with specialty resources (i.e. medical and legal) to proactively pursue claim resolution opportunities, (i.e. return to work, structured settlement, and discontinuation of benefits through litigation.
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Develops and manages workers compensation claims' action plans to resolution, coordinates return-to-work efforts, and approves claim payments. Description: PRIMARY PURPOSE: To analyze mid- and higher-level workers compensation claims to determine benefits due; to ensure ongoing adjudication of claims within company standards and industry best practices; and to identify subrogation of claims and negotiate settlements.
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With close to moderate supervision, may handle claims of greater complexity where Injured worker (IW) remains out of work and unlikely to return to position. The injured worker as returned to work, reached Maximum Medical Improvement (MMI) and is receiving PPD benefits.
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Communicates with internal managed care and medical resources to ensure coordination with medical providers, injured workers and employers in developing return to work strategies and treatment plans.
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Effectively manages disability via the Return-to-Work Program, which includes securing job descriptions and Policyholder education about the benefits of providing light duty. Return to Work Program.
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workers compensation complex return to work jobs
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