Have you worked with workers’ compensation claims? Do you have experience interpreting industrial insurance rules and regulations? Do you have experience administering time-loss and treatment only claims?
Would you like to work with a group of dynamic, dedicated, passionate people who are committed to transforming healthcare in the state of Washington? If this sounds like something you would like to be part of, we want to talk to you about a career with Washington Hospital Services, a subsidiary of the Washington State Hospital Association.
WSHA has been in existence for over 85 years and continues to grow and evolve as the needs of Washington Residents and our member hospitals change. We are located in beautiful downtown Seattle, surrounded by wonderful views of Puget Sound and the Olympic mountains, with easy access to transit and underground parking, and we are currently recruiting for a Workers’ Compensation Time Loss Adjudicator to join our Workers’ Compensation team.
The Workers’ Compensation Time Loss Adjudicator adjudicates and manages the Self-Insured Public Hospital District and Washington Hospital Workers’ Compensation time loss and treatment only claims. This position regulates self-insured workers’ compensation claims for compliance with the Industrial Insurance Laws Title 51 (RCW), Medical Aid Rules and other statutes related to industrial insurance. This position will report to the Assistant Director of Client Services and Compliance in our wholly owned for-profit subsidiary, Washington Hospital Services (WHS), and will be expected to fully manage the entire life cycle of a workers’ compensation claim.
Specific duties of this position include, but are not limited to:
- Adjudicate workers’ compensation claims to interpret facts and apply laws to determine claim validity and is responsible for the ongoing appropriate and timely claim management activities necessary to bring resolution at the earliest possible time in a cost-effective manner.
- Calculate monthly gross earnings and daily time loss rates for the purposes of issuing accurate and timely benefit payments.
- Ensure initial disability benefit payments are issued within 14 days of notice of receipt of claim and ongoing benefit payments are issued every 14 days.
- Initiate and complete the 3-point contact within 48 hours of receipt of a new claim.
- Establish initial case reserves for the life of each claim at the time of initial claim review and review case reserves every 60 days making necessary adjustments based upon anticipated indemnity, medical, vocational, legal or other costs.
- Conduct a comprehensive file review, take appropriate actions, and complete a Claim Status Summary Report and written Plan of Action (POA) every 60 days.
- Maintain a current claims diary, defined per performance standards.
- Complete timely review and acknowledge receipt of claim documents, record document note entry, take appropriate action and record actions taken in response to documents received and reviewed.
- Review claim file documents to evaluate need for ongoing disability certification, authorize or deny requests for medical treatment, surgery, diagnostic studies, transfers of medical care, refer for vocational, investigative or legal services and/or submit claim for closure.
- Review determinative orders received from the Department of Labor & Industries for the purposes of ensuring they are accurate and represent our interpretation of the facts of the claim and file timely protests or appeals as warranted.
- Evaluate medical reports to determine appropriate permanent partial disability awards.
- Communicate both verbally, and in writing with Department of Labor & Industries staff, designated hospital contacts, physicians, injured workers, claimant and employer attorneys, and other stakeholders.
- Develop and maintain a professional and positive working relationship with all stakeholders.
- Secure, manage and direct the services of outside specialty providers (e.g., independent medical providers, vocational counselors, nurse case managers, defense counselors, and investigators).
- Identify and update injured worker’s physical restrictions and assist clients in the return to work accommodation process; determine the need for vocational services and approve or deny formal vocational plans.
- Investigate and pursue Third Party subrogation claims.
- Approve medical payments on claim files on a weekly basis.
- Prepare claims for closure with the Department of Labor & Industries or close claims in-house following appropriate procedures.
- Complete claim status reviews with clients on a quarterly basis (telephone, web-based or onsite).
- Work with Unemployment Program staff on joint accounts to coordinate documentation in an effort to discover fraudulent concurrent claims and reduce costs.
- Work with designated hospital contacts answering questions, educating and updating them on an ongoing basis with regard to their assigned duties.
- Attend and represent Washington Hospitals Services Workers’ Compensation Program at self-insured meetings, seminars and other meetings as designated.
- Perform other duties as assigned.
Desired qualifications, skills, and abilities
- Bachelor’s degree in business, marketing, or related field or equivalent combination of education and experience.
- Three years’ experience working with Workers Compensation claims, including processing both time loss and treatment only claims.
- Must have or obtain a Claims Administrator certificate from Washington State L&I within 1 year of employment with WHS and maintain it for the duration of employment.
- Demonstrated knowledge of relevant state laws (RCW 51 and WAC 296)
- Exceptional customer/member service skills and superior interpersonal and communication skills required.
- Demonstrated ability to exercise sound judgment and maintain confidentiality.
- Strong analytical and organizational skills, detail orientation required.
- Must be a self-starter and innovator.
- Ability to work successfully independently or in a collaborative, team environment.
- Ability to successfully manage multiple priorities simultaneously.
- Access to a vehicle and ability to periodically travel within Washington State to member hospitals.
- Proficient with MS office, Outlook, Word, Excel required. Familiarity with Workers’ Compensation databases, experience with paperless systems and knowledge of computerized claims processing required, knowledge of ERIC system a plus.
If you have the skills and abilities listed above, feel that you would be a good fit for this position and would like to be part of this exceptional organization, please apply through our career center at the following URL for immediate consideration.
Remote work currently available temporarily due to COVID pandemic. Local candidates preferred. No calls please. WSHA is an Equal Opportunity Employer.