Job Description

Safe Choice Claims Specialist II

Under the Safe Choice Claims Manager, the Safe Choice Claims Specialist II reviews, studies, and processes assigned claims within their authority. The goal is to provide prompt, efficient service while protecting the organization's assets. The Claims Specialist II's main duty involves using discretion and independent judgment on important financial and confidential matters.

HYBRID position - 2 days onsite each week - Dallas, TX

Essential Functions of the Role:

• Promptly investigate assigned non-subscription claims to assess liability and entitlement to benefits.
• Confirm applicable coverage. Maintain compliance with ERISA plan document, insurance policies, and procedure manuals. Take recorded statements. Establish reserve requirements. Identify subrogation potential. Maintain diary.
• Review and evaluate medical and lost wages. Conduct a thorough investigation of the claim by contacting witnesses. Provide status reports to management as needed.
• Resolve complex, severe exposure claims, using high service-oriented file handling.
• Responsibility for the preparation of summaries and files for denials, appeals, medical advice, subrogation, and litigation.
• Collection of documents and summarizing information.
• Providing presentations for committee meetings and any required correspondence.
• Apply technical knowledge and human relations skills to ensure fair and prompt case disposal. Contribute to a reduced loss ratio.
• Assign surveillance on appropriate claims.
• Identifying claims with possible recovery from third parties.
• Maintain communication with doctors, attorneys, safety specialists, nurse specialists, and vendors. Provide prompt, economical, and professional handling of all claims.
• Talking to others to convey information effectively.
• Communicating effectively in writing as appropriate.
• Provide and coordinate training with HR team.
• Work with Claims Manager for improvements in processes to increase proficiency and supervise effective resolution of all claim inquiries.
• Responsible for the approval of lost wages for payroll and for all approvals of medical bills per claim file.
• Pay and process claims within designated authority level.
• Performs other position-appropriate duties as required in a competent, professional, and courteous manner.

Key Success Factors:

• Can substitute Bachelor's degree for years of experience.
• Texas All Lines Adjuster License, Non-subscription Experience strongly preferred.
• 2 years work related injury claims experience strongly preferred

Qualifications:

• EDUCATION - H.S. Diploma/GED Equivalent
• EXPERIENCE - 5 Years of Experience

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