Primary Function

As a Workers’ Comp Claims Coordinator is responsible for the investigation, evaluation, disposition and settlement of the most complex claims and highest exposures. This includes the investigation, determination and evaluation of coverage, liability and damages, and the evaluation of proper reserves.

Nature and Scope (Essential Functions)

1. Exercises proper judgment and decision making to analyze the claims exposure, to determine the proper course of action to appropriately settle the claim
2. Interacts extensively with various parties involved in the claim process
3. Utilize critical thinking and solid judgment to solve problems, make decisions and resolve complex issues inherent in handling losses, as well as plan and organize activities throughout the claims management process
4. Communicate with external claims adjuster to enable the successful settlement and disposition of serious claims.
5. Documents and communicates all claim activities timely and effectively and in a manner which supports the outcome of the claim file
6. Handles claims consistent with "Best Practices", and also in accordance with any statutory, regulatory and ethics requirements
7. The incumbent directs services and management training related to workers’ comp.
8. The incumbent is responsible for keeping abreast of relevant issues that impact workers’ comp and communicates to members of the administrative team, facilities management team and facilities human resources departments.
9. The incumbent will review the investigation documentation thoroughly and make appropriate recommendations to resolve concerns brought to the attention of administration, human resources departments.
10. The incumbent is responsible for coordinating weekly claims review meetings with appropriate parties to ensure the handling of WC claims is being done accurately and timely.
11. The incumbent works in collaboration with internal and external resources in order to achieve best outcomes.
12. The incumbent develops an operating budget, monitors, analyses and implements controls to ensure that the assigned areas operate within approved budget.
13. The incumbent develops and analyses reports to provide educated sound recommendations related to programs and other activities related to workers’ comp.
14. The incumbent participates in developing, implementing and evaluating programs to effectively impact the workers’ compensation program.
15. The incumbent ensures regulatory compliance.
16. Incumbent is responsible for managing the workers’ compensation claims in compliance with all state and federal laws.
17. Keeps immediate supervisor informed of any benefit related concerns/issues and collaborates to address issues on a timely basis.
18. Works collaboratively with AHMC colleagues to deliver exceptional customer service and build cohesive interdepartmental relationships.
19. Assists the facilities in addressing complex WC claim issues.
20. Performs other duties as assigned or required.

Qualifications

1. Bachelor’s (BS or BA) degree in a field of study related to this position preferred.
2. Minimum 5 years experience as a workers’ compensation adjuster.
3. Five or more years of claims-related experience with a consistent high level of performance and achievement
4. Workers’ Compensation Claims Administrator Certificate (WCCA) and/or Workers’ Compensation Claims Professional (WCCP) preferred but not required.
5. Extensive knowledge of accepted industry standards and practices
6. Ability to effectively operate a computer, knowledge of MS Office applications, and related claims and business software.
7. Knowledge state workers’ compensation laws.
8. Possess excellent negotiating skills and communication skills.
9. Ability to communicate effectively with internal and external resources.
10. Must possess excellent human relation skills.
11. Must possess excellent critical thinking skills.
12. Possess strong organizational skills with ability to multi-task, and prioritize workload.

Accountability

1. The incumbent is responsible for managing the workers’ comp cases to achieve targeted outcomes.
2. This position is responsible for promoting an environment of teamwork with all members of the organization.
3. The incumbent is responsible for assuring the assigned area(s) are in compliance with hospital policies and procedures.
4. This position is accountable for meeting budgetary expectations.
5. This position is responsible for assuring departments are in compliance with the organization’s workers’ comp policies and procedures.
6. The incumbent is accountable for communicating to the internal resources of any possible issues which may arise in order to proactively develop an action plan to minimize or eliminate the issue.
7. The incumbent is responsible for acting in an ethical manner at all times.
8. The incumbent is accountable for maintaining confidentiality on sensitive matters.
9. The incumbent is responsible for complying with all company policies and procedures.
10. The incumbent is responsible for complying with all local, state and federal laws.

Dimensions

AHMC provides management services to AHMC Anaheim Regional Medical Center with 223 beds, Garfield Medical Center with 211 beds, Greater El Monte Community Hospital with 115 beds, Monterey Park Hospital with 102 beds, San Gabriel Valley Medical Center with 273 beds, Seton Medical Center with 357 beds, Seton Medical Center Coastside, a 116-bed skilled nursing facility, and Whittier Hospital Medical Center with 172 beds. The facilities are Medicare and Medi-Cal certified and accredited by The Joint Commission on Accreditation of Healthcare Organizations. The hospitals provide healthcare services reimbursed by Medicare, Medi-Cal, traditional insurance plans, PPO, HMO and under capitated arrangements.