Full Job Description
HCR ManorCare provides a range of services, including skilled nursing care, assisted living, post-acute medical and rehabilitation care, hospice care, home health care and rehabilitation therapy.
The HCR ManorCare team is recruiting for a Claims Administrator II. The Claims Administrator II is responsible for administration of workers' compensation claims, assists with administration of workers' compensation program, communicates with the appropriate facility personnel on workers' compensation matters. Has authority to set reserves and negotiate settlements up to designated limits.
General Claims Program
1. Evaluates industrial injuries to determine compensability; Conducts a thorough investigation to ensure that all pertinent information is available prior to claim certification; Makes appropriate referral for disability management.
2. Reports claims and employees position on compensability to appropriate state agency in a timely manner.
3. Interacts with facility to gather all information regarding work related injuries, direct facility personnel on proper accident investigation.
4. Assesses claim to determine if surveillance is necessary; Moves forward with surveillance with department manager’s approval.
5. Determines the necessity of Independent Medical Evaluations (IMEs) in adherence with state law.
6. Determines need for treatment based on recognized condition of claimant.
7. Evaluates, initiates and negotiates full and final claim settlements, when appropriate; Has authority to negotiate settlements up to $15,000 with the agreement of location administrator.
8. Reports all issues to assigned department manager that could have an adverse affect on the workers' compensation program; Reports all safety concerns to the safety manager.
9. Monitors and audits safety coordinator activity reports and progress to determine effectiveness and/or needs for training and assistance.
10. Provides day-to-day support and back-up for intake specialist, claims examiner, and other claims administrators.
11. Prepares claim files for state; Attends required state claim audits.
Self Insured Claims Administration
1. Establishes proper claims reserves and reports excess insurance carrier when required and continues to apprise excess carrier as indicated; Has authority to set reserves up to $15,000 without manager approval.
2. Processes initial workers' compensation claim according to statutory guidelines and works to bring file to case closure in an expeditious manner.
3. Evaluates and issues disability benefits and medical payments according to statutory guidelines, which includes but is not limited to wage calculation and medical fee bill review for adjustment to fee schedules and UCR limits.
4. Interacts with medical providers, disability managers, facility personnel and injured workers to expedite successful return to work.
5. Assesses and determines appropriate rehabilitation needs; Assists in determining appropriate work accommodations and or vocational retraining and implements accordingly.
6. Attends and represents HCR ManorCare at workers' compensation administrative hearings and/or mediation.
7. Refers claim to legal counsel when appropriate and monitors coordinate representation.
8. Maintains knowledge of state statutory changes within the workers' compensation system to ensure HCR ManorCare compliance.
9. Prepares quarterly reports on claim status for distribution to centers; Meets with administrators, regional managers, and facility personnel in charge of the centers workers' compensation files to discuss the status of their workers' compensation program.
Insured Claims Administration
1. Sets up claim file for monitoring and evaluation.
2. Communicates with the Third Party Administrator to insure aggressive claims management and assists in performance reviews.
3. Communicates with facility to insure all facts are made available to the Third Party Administrator; Meets with administrators regarding problem claims.
4. Evaluates reserves for sufficiency, negotiates settlements, performs field audits, encourages claim closure in a timely manner and provides assistance when litigation is necessary; authority limits previously noted apply.
5. Keeps manager apprised of difficulties/problems that requires attention.
1. Attends and participates in scheduled in-service programs and staff meetings.
2. Maintains confidentiality of necessary information.
3. Utilizes supplies and equipment properly and without waste.
4. Thinks and acts calmly and logically to meet unusual occurrences of the job without being thrown off stride.
5. Performs any miscellaneous work assignments as may be required.
1. Education: Associate's degree required; Bachelor's degree in business, health care administration, or nursing preferred.
2. Experience: Three to five years workers' compensation claims management required; 1-3 years medical benefits, managed care, or related HR experience desirable.
3. Physical Demands: Primarily sedentary in nature with lifting ten pounds; Primarily involves sitting, reaching, handling, fingering, talking, hearing and seeing.
4. Travel: less than 25%
5. Working Conditions: Inside in well-lighted, well-ventilated areas.
6. Principal Contacts: Third party administrators, legal counsel, center administrators, regional managers.
7. General Requirements: Must be able to execute all terms and conditions set forth in the HCR ManorCare Employee Handbook, including, but not limited to:
a. Works in a safety-conscious manner which ensures that safe work practices are used in order not to pose a risk to self or others in the workplace.
b. Complies with company policies and procedures and local, state, and federal regulations.
c. Adheres to policy on Drug Free Workplace.
d. Interacts in a tactful, diplomatic, and humanistic manner with residents, families, visitors, and co-workers to provide a safe, efficient, and therapeutically effective caring environment which ensures the self-respect, personal dignity, rights and physical safety of each resident and center guest.
e. Maintains a dependable attendance record and adheres to standards of cleanliness, grooming, hygiene, and dress code.
f. Takes positive action to ensure equal opportunity in the conduct of all business activities without regard to race, color, religion, sex/gender, age, national origin, disability, citizenship, veteran status or any other legally protected category.
ProMedica is a mission-based, not-for-profit integrated healthcare organization headquartered in Toledo, Ohio. It serves communities in 28 states. The organization offers acute and ambulatory care, an insurance company with a dental plan, and post-acute and academic business lines. The organization has more than 56,000 employees, 13 hospitals, 2,100+ physicians and advanced practice providers with privileges, 900+ healthcare providers employed by ProMedica Physicians, a health plan, and nearly 400 assisted living facilities, skilled nursing and rehabilitation centers, memory care communities, outpatient rehabilitation clinics, and hospice and home health care agencies. Driven by its Mission to improve your health and well-being, ProMedica has been nationally recognized for its advocacy programs and efforts to address social determinants of health. For more information about ProMedica, please visit www.promedica.org/aboutus.
Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex, pregnancy, sexual orientation, gender identity or gender expression, age, disability, military or veteran status, height, weight, familial or marital status, or genetics.
Equal Opportunity Employer/Drug-Free Workplace