Claims Specialist

Interested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and communities entrusted to our care. By joining Parkland, you become part of a diverse healthcare legacy that's served our community for more than 125 years. Put your skills to work with us, seek opportunities to learn and join a talented team where patient care is more than a job. It's our passion.

Primary Purpose

• This position is responsible for Workers' Compensation and/or liability and Insurance Claims Administration
• Workers' Compensation responsibilities include Claims Adjusting, Workplace Safety Coordination, Coordinating the Workers' Compensation Labor Pool, Transitional Work Assignments, Report Development, and various compliance issues related to the Texas Department of Insurance to ensure effective operations.
• Liability and Insurance Claims include Administration of Claims, Adjusting, Legal Coordination, Insurance Coordination, Claimant Communication and Record Keeping.

Minimum Specifications

Education

• Bachelor's Degree in Risk Management, Business Administration, Organizational Development, or a related field of study preferred.

Experience

• 3 plus years of experience in a Workers' Compensation or Claims administrative environment.

Equivalent Education and/or Experience

• May have an equivalent combination of education and experience to substitute for both the education and experience requirements.

Certification/Registration/Licensure

• Texas Department of Insurance Workers' Compensation Adjuster License is required within 90 days of hire or reclassification into the position - OR
• All Lines Adjuster license required within 90 days of hire or reclassification into the position.

Skills or Special Abilities

• Must be able to demonstrate a working knowledge of current State Department of Insurance requirements, and its accompanying laws, standards, and guidelines.
• Must have knowledge regarding claims adjusting and loss prevention.
• Must be able to plan, design, and implement cross-departmental reports and delegate their build.
• Must have good verbal and written communication skills to effectively communicate with the public, physicians, and all levels of staff.
• Must be detail oriented. Must have a working knowledge of database software including in-house and TPA claims management software.
• Must be able to organize information and draw logical conclusions.
• Must have knowledge of and working experience with the Family Medical Leave Act.

Responsibilities

1. Reviews, investigates, and ensures proper reporting of all workers' compensation claims and/or liability and insurance claims. Conducts frequent and ongoing reviews of each case to ensure the file is reserved appropriately, documented timely, and that the insurance adjuster has implemented an aggressive action plan to resolve each claim in a timely and cost-efficient manner in applicable claims.
2. Administrates the Return-to-Work Transitional Duty Process. Coordinates with employees' supervisors to ensure a smooth return to full duty. Ensure employee, supervisor, and the Office of Talent Management are all updated on changes.
3. Works with internal and external legal counsel in determining compensability of claims.
4. Create key strategic initiatives to improve the Claims program and procedures. Identify and execute upon opportunities for improved efficiencies and enhanced risk management.
5. Serves as the point of contact for all internal and external stakeholders, including but not limited to Third Party Administrators, Provider Networks, Texas Department of Insurance, and attorneys, regarding the administration, management, rules and regulations, and requirements of claims.
6. Audits Third Party Administrator's and legal firm's check register to ensure billing accuracy and validity. Research billing and payment issues between providers, medical facilities, and claims administrator. Serves as the point of contact for concerns regarding benefits and claim status.
7. Reconciles actual to budget claims performance and determines cause of variance. Develops action plans to address significant variations.
8. Develops key performance and key risk indicators to ensure efficient program management.
9. Develops and delivers programs designed to minimize Parkland's overall exposure to claims and liabilities, which may include policy and procedure buildout, committee and/or workgroup coordination, and stakeholder communication.
10. Responsible for Report Development activities which include initiating technical designs for trending reports to analyze injury causes for both internal and external customers. Creates and maintains reports and automates report distribution. Researches and implements new reporting and online technology.

Job Accountabilities

1. Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of the department and Parkland.
2. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
3. Maintains knowledge of applicable rules, regulations, policies, laws, and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and federal, state, and private health plans. Seeks advice and guidance as needed to ensure proper understanding.

Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.As part of our commitment to our patients and employees' wellness, Parkland Health is a tobacco and smoke-free campus.