VP or DIRECTOR OF WORKERS’ COMPENSATION CLAIMS, RISK & LOSS
This position is responsible for developing and implementing workers compensation risk management, loss control and claims management strategies designed to minimize risk, aggressively handle claims and control costs by incorporating industry best practices. This position is also responsible for ensuring compliance with industry changes and regulatory requirements.
Fostering positive and mutually beneficial relationships with fund members and TPA clients through
on-site visits and other business-related venues is of paramount importance to this position.
ESSENTIAL FUNCTIONS & RESPONSIBILITIES
• Develops, implements, monitors, and directs comprehensive high-quality WC Risk Management & Loss Prevention plans, strategies and programs that support best practices resulting in superior results; oversees WC claims management services and related vendor business
relationships necessary to ensure appropriate outcomes in the best interest of TPA clients and Fund members.
• Evaluates and improves existing programs to ensure they are providing the best results and are in
compliance with regulatory requirements.
• Ensures that the Fund loss prevention program is cutting edge and effective in reducing overall loss experience.
• Ensures that all claims management and cost containment strategies are cutting edge and effective in reducing the overall cost of claims.
• Supports and continually keeps fresh the brand identity that sets the Fund and company apart from its competitors.
• Hires, retains, trains and develops qualified workers’ compensation claim, risk and loss prevention staff capable of providing meaningful solutions that are effective in overall loss experience.
• Performs all personnel functions related to the management of an effective WC claims and loss prevention service team, including performance evaluations, corrective action, career guidance, training and staffing for all direct reports.
• Compiles WC claims, risk data and loss prevention data, and produces reports as required and/or requested.
• Monitors outcomes of workers’ compensation claims, risk and loss prevention staff’s contact with members and TPA clients. Compiles member performance information for evaluation of member and client satisfaction along with service effectiveness. Monitors and responds to problems. Conducts client surveys for all workers’ compensation-related services and programs.
Manages the medical bill re-pricing to ensure properly adjusting all provider bills to the appropriate fee.
This involves coordinating the efforts of in-house staff as well as the outside vendors used for repricing and specialty bill review services.
• Coordinates and manages the pharmacy vendor network to ensure proper payment of prescription drugs at discounted rates.
• Provides final reserve, settlement and payment authority above the WC Claims Supervisor. Oversees the large exposure WC claims through the STARS diary system.
• Responds to service needs of all Fund members and WC TPA clients.
• Participates in the budgetary process for the WC service team.
• Develops and prioritizes topics for workers’ compensation educational seminars, newsletters, and service programs.
• Develops and manages the annual WC Symposium.
• Minimum of an undergraduate college degree and five years experience handling workers’ compensation claims and/or field experience as a risk manager or loss prevention consultant, plus five
years of claims management or supervision of claims staff or equivalent experience.
• Post grad studies, advanced degrees and/or industry-specific credentials related to claims and risk management is desirable and a plus for this position.
• Possess good communication and interpersonal skills with clients and staff.
• Strong computer skills, including experience with database software, etc.
• Proven problem solving, negotiating, and organizational skills.
• Possess leadership skills.
• Ability to delegate.
• Ability to travel with flexibility as necessary.
This position reports to the Executive Vice President, Operations
Responsible for the day to day operations of the claims processing unit including bill processing, timeliness of
medical and indemnity check processing and all other aspects of the administrative claims function