Workers' Compensation Claims Analyst

Advocate Health Care; Oak Brook (IL); On-site; USD 65,000 - 90,000; Full time

Job summary

Advocate Health Care is seeking a Workers Compensation Claims Analyst to adjudicate medical-only claims and limited lost-time workers’ compensation claims. The role involves collaborating with case managers, attorneys, and vendors to manage subrogation liens and negotiate settlements.

The analyst will monitor costs, document electronic files, reserve files timely, and coordinate light duty as needed. Strong analytical and confidentiality skills are essential for success in this role.

Qualifications

• Bachelor’s degree or combination of education and related experience.
• Adjusters license for assigned jurisdiction as applicable.

Responsibilities

• Adjudicate medical-only claims and limited lost-time workers’ compensation claims.
• Work with case managers, attorneys, and vendors.
• Manage subrogation liens and negotiate settlements.
• Monitor costs, document electronic claim files, and reserve files.
• Communicate claim status to injured teammates and others as needed.
• Develop action plans for prompt payment/denial and report to excess carriers.
• Redirect treatment to network physicians and authorize related expenses.

Skills

Analytical skills

Urgency & accuracy

Communication

Confidentiality

Team collaboration

Education

Bachelor’s degree

Associates in Claims designation preferred

Job description

The Workers Compensation Claims Analyst is a critical thinker who manages claims within organizational standards and best practices. They are responsible for the adjudication of medical only claims and limited lost time workers' compensation claims. They will work closely with case managers, attorneys, and vendors. They will manage subrogation liens and negotiate claim settlements to achieve the best possible outcome and support the goals of the department.

Major Responsibilities

• Must possess analytical skills and be able to work with a sense of urgency and accuracy. Must be able to adhere to multiple state workers’ compensation rules, regulations, and laws.
• Must be able to complete appropriate contacts within 24 hours of assignment, establish and maintain appropriate diary for follow-up, evaluates and determines compensability of workers’ compensation claims within the statutory period for multiple jurisdictions.
• Must be able to be responsible for monitoring and controlling costs, timely documentation of the electronic claim file, claim outcome, timely reserving of files, managing subrogation and litigation, filing appropriate forms and payment of all benefits due within statutory periods and coordinates light duty as needed.
• Must function as a resource to the injured teammates, leaders, and others with an interest in the claim.
• Must be able to communicate claim status with the injured teammate and other parties, as necessary.
• Must be able to develop action plans and strategies for prompt payment/denial of claims bringing them to a timely conclusion while providing all appropriate information. Must be able to monitor and report appropriate claims to excess carriers.
• Must be able to determine what treatment is appropriate and causally related to the compensable injury and redirect treatment to network physicians as appropriate. Must be able to promptly authorize and approve related expenses of the claim.
• Must be able to maintain strict confidentiality of information at all times of a sensitive nature and/or protected under state and federal law.
• Must be able to develop and maintain professional customer relationships. Must be able to provide education as needed and serve as a mentor to other adjusters and stakeholders.
• Must be able to provide additional support for additional projects and duties as assigned.

Education Requirements

• Adjusters license for assigned jurisdiction as required by specific jurisdiction as applicable.
• Bachelor’s degree required or a combination of education and related experience.

Experience Requirements

• 2-5+ years’ experience managing progressively difficult Workers Compensation lost time claims. Associates in Claims designation preferred.

Knowledge, Skills & Abilities Required

• Must be competent in workers’ compensation rules, regulations, and laws for multiple jurisdictions.
• Must work with a sense of urgency and accuracy.
• Evaluates and determines compensability of workers’ compensation claims within the statutory limits for multiple jurisdictions.
• Must be able to work independently as well as part of a team.
• Access to protected Health Information (PHI) to the extent of information necessary to do the job. Information shared only on a need-to-know basis.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.