Claim Specialist
GovernmentJobs.com, Austin, TX, United States
Claims Specialist
This position is responsible for investigating and managing Workers' Compensation claims to ensure accurate and timely benefit administration while safeguarding Members' pooled funds. It involves assessing claim compensability, coordinating medical treatment, and facilitating claim resolution in compliance with Texas Workers' Compensation regulations. This position also requires effective communication with injured workers, medical providers, and fund members to support fair and efficient claims handling. Required Responsibilities: Conducts thorough investigations of Workers' Compensation claims to determine compensability, including interviews with Members, claimants, and witnesses, and reviews medical reports, personnel files, and other relevant documents. Calculates and administers indemnity benefits, including Temporary Income Benefits (TIB), Impairment Income Benefits (IIB), Supplemental Income Benefits (SIB), Death Benefits (DB), Lifetime Income Benefits (LIB), multiple employment, adjusted benefits, and benefits checks with multiple payees in accordance with the Texas Workers' Compensation rules. Maintains and manages claims to conclusion by coordinating with Members, medical providers, preauthorization and injured workers to drive claim towards resolution. Effectively document the claim file per the Pool's Service Level Objectives. Coordinates with vendors for the management of Peer Reviews, Designated Doctor (DD) exams, and Post-DD Required Medical Examinations. Ensure compliance with doctor's orders, medical instructions and the Texas Labor Code. Prepares cases for dispute resolution and participates in hearings and dockets to support claim resolution. Handles incoming communications, including phone calls and emails, and ensures the accuracy of documents received from fund members, requesting corrections when necessary. Shares responsibility for the emergency after-hours line. Assists in training and educating Members on Workers' Compensation processes and procedures. Conducts periodic eligibility checks on beneficiaries to verify continued qualification for benefits. Submits required documentation to the Division of Workers' Compensation within mandated deadlines. Reviews and processes incoming documents, including legal and expense invoices, medical bill payments, travel reimbursements, and work status reports, while maintaining organized and properly labeled claim files. Education, Work Experience, Certifications Required: B.A. or B.S. degree in Business, Insurance, Risk Management, or related field Years of Experience: 3 Area of Experience: Workers' Compensation Texas Department of Insurance All Lines or Workers' Compensation Adjuster License Essential Competencies and Skills Required: Valid Texas driver's license and a good driving record Possess knowledge and understanding of relevant laws, rules, and regulations Excellent decision-making and problem-solving skills Excellent oral and written skills Proficiency in MS Excel Proficiency in MS Word Proficiency in MS PowerPoint Proficiency in MS Outlook Equal Opportunity: The Texas Municipal League Intergovernmental Risk Pool is an Equal Opportunity Employer and welcomes applications from all qualified applicants. We do not discriminate on the basis of race, color, religion, sex, national origin, age, marital status, medical condition, disability, or sexual orientation. Reasonable Accommodation: The Texas Municipal League Intergovernmental Risk Pool makes reasonable accommodations for the disabled. If you believe you require special arrangements to participate in the testing process, you must inform the People Resources Department in writing no later than the filing date. Applicants who request such accommodation must document their request with an explanation of the type and extent of accommodation required. At the Texas Municipal League Intergovernmental Risk Pool, we value our team and offer a robust benefits package designed to support your health, well-being, and future: Medical Insurance 100% employer-paid for employees, with subsidized coverage available for dependents Dental & Vision Insurance 100% employer-paid comprehensive coverage for you and your family Flexible Spending Accounts (FSA) for healthcare and dependent care expenses Health Savings Account (HSA) additional support for medical expenses Texas Municipal Retirement System (TMRS) with a generous 2:1 employer match 457(b) Deferred Compensation Plan 6.2% employer contribution to support long-term financial planning Disability Insurance 100% employer-paid short-term and long-term disability coverage Life and AD&D Insurance 100% employer-paid coverage that provides added financial protection Paid Time Off includes 9 holidays, vacation, sick leave, and personal holidays Education Assistance up to $6,000 annually to support your continued learning and professional development
This position is responsible for investigating and managing Workers' Compensation claims to ensure accurate and timely benefit administration while safeguarding Members' pooled funds. It involves assessing claim compensability, coordinating medical treatment, and facilitating claim resolution in compliance with Texas Workers' Compensation regulations. This position also requires effective communication with injured workers, medical providers, and fund members to support fair and efficient claims handling. Required Responsibilities: Conducts thorough investigations of Workers' Compensation claims to determine compensability, including interviews with Members, claimants, and witnesses, and reviews medical reports, personnel files, and other relevant documents. Calculates and administers indemnity benefits, including Temporary Income Benefits (TIB), Impairment Income Benefits (IIB), Supplemental Income Benefits (SIB), Death Benefits (DB), Lifetime Income Benefits (LIB), multiple employment, adjusted benefits, and benefits checks with multiple payees in accordance with the Texas Workers' Compensation rules. Maintains and manages claims to conclusion by coordinating with Members, medical providers, preauthorization and injured workers to drive claim towards resolution. Effectively document the claim file per the Pool's Service Level Objectives. Coordinates with vendors for the management of Peer Reviews, Designated Doctor (DD) exams, and Post-DD Required Medical Examinations. Ensure compliance with doctor's orders, medical instructions and the Texas Labor Code. Prepares cases for dispute resolution and participates in hearings and dockets to support claim resolution. Handles incoming communications, including phone calls and emails, and ensures the accuracy of documents received from fund members, requesting corrections when necessary. Shares responsibility for the emergency after-hours line. Assists in training and educating Members on Workers' Compensation processes and procedures. Conducts periodic eligibility checks on beneficiaries to verify continued qualification for benefits. Submits required documentation to the Division of Workers' Compensation within mandated deadlines. Reviews and processes incoming documents, including legal and expense invoices, medical bill payments, travel reimbursements, and work status reports, while maintaining organized and properly labeled claim files. Education, Work Experience, Certifications Required: B.A. or B.S. degree in Business, Insurance, Risk Management, or related field Years of Experience: 3 Area of Experience: Workers' Compensation Texas Department of Insurance All Lines or Workers' Compensation Adjuster License Essential Competencies and Skills Required: Valid Texas driver's license and a good driving record Possess knowledge and understanding of relevant laws, rules, and regulations Excellent decision-making and problem-solving skills Excellent oral and written skills Proficiency in MS Excel Proficiency in MS Word Proficiency in MS PowerPoint Proficiency in MS Outlook Equal Opportunity: The Texas Municipal League Intergovernmental Risk Pool is an Equal Opportunity Employer and welcomes applications from all qualified applicants. We do not discriminate on the basis of race, color, religion, sex, national origin, age, marital status, medical condition, disability, or sexual orientation. Reasonable Accommodation: The Texas Municipal League Intergovernmental Risk Pool makes reasonable accommodations for the disabled. If you believe you require special arrangements to participate in the testing process, you must inform the People Resources Department in writing no later than the filing date. Applicants who request such accommodation must document their request with an explanation of the type and extent of accommodation required. At the Texas Municipal League Intergovernmental Risk Pool, we value our team and offer a robust benefits package designed to support your health, well-being, and future: Medical Insurance 100% employer-paid for employees, with subsidized coverage available for dependents Dental & Vision Insurance 100% employer-paid comprehensive coverage for you and your family Flexible Spending Accounts (FSA) for healthcare and dependent care expenses Health Savings Account (HSA) additional support for medical expenses Texas Municipal Retirement System (TMRS) with a generous 2:1 employer match 457(b) Deferred Compensation Plan 6.2% employer contribution to support long-term financial planning Disability Insurance 100% employer-paid short-term and long-term disability coverage Life and AD&D Insurance 100% employer-paid coverage that provides added financial protection Paid Time Off includes 9 holidays, vacation, sick leave, and personal holidays Education Assistance up to $6,000 annually to support your continued learning and professional development