Position Title: Injury Benefit Coordinator
EOE
Position Summary
The Injury Benefit Coordinator (IBC) is the primary claim handler on the Work Injury team. From the moment a new claim is received, the IBC owns it from inception to closure, through investigating compensability, managing benefits in accordance with each client’s Work Injury Benefit Plan under the Employee Retirement Income and Securities Act of 1976 (ERISA), coordinating medical care and return-to-work efforts, and serving as the central point of contact for injured employees, employer clients, medical providers, and vendors.
This is a complex, high-judgment role that requires strong analytical skills, knowledge of ERISA and client-specific plan requirements, and the ability to manage a demanding workload without losing accuracy or compassion. The IBC is supported by a Claims Assistant and Claims Analyst Triage, and is expected to direct their work effectively while maintaining full accountability for the claims they manage.
The statements contained herein reflect the key functions and expectations of this position and are not intended to be an all-inclusive listing of work requirements. Employees may perform other duties as assigned, including cross-functional support to balance workload or cover absences.
Essential Functions
· Approach all communication with injured workers with compassion, professionalism, and respect, recognizing that claimants are often navigating a difficult and stressful time.
· Develop and maintain thorough working knowledge of each assigned client's Work Injury Benefit Plan and Providence’s Pertinent Claim Requirements (PCR), applying plan provisions accurately throughout the life of every claim.
· Adjudicate and actively manage work injury claims for assigned clients from inception to closure in accordance with Work Injury Benefit Plans, client service instructions, and Providence’s Best Practices.
· Receive, review, and investigate all new claims for compensability, potential liability, denial indicators, and fraud risks through 4-point contact (employer, claimant, witness, and medical provider).
· Direct new claims to the assigned Claims Data Analyst for file set-up in the claims management system, and to the Claims Analyst Triage for completion the initial 4-point contact.
· Set appropriate reserves based on claim facts; evaluate and adjust as circumstances evolve throughout the life of the claim.
· Prepare and submit check request forms or determine calculations and delegate task to the Claims Assistant.
· Develop and document strategies and routine plans of action on open, active claims as directed by the PCR or client protocol.
· Monitor injured employees’ compliance with Plan rules; generate and issue non-compliance letters as needed.
· Identify and escalate serious or catastrophic claims to management immediately upon discovery.
· Place excess carriers on timely notice of claims that meet their reporting criteria.
· Track and adhere to all HIPAA privacy requirements, Department of Labor regulations, and all applicable state deadlines throughout the claim handling process.
· Assign and coordinate medical case management on claim files as needed, in accordance with client service instructions and Providence’s Best Practices.
· Monitor, verify, and authorize or deny prescriptions in pharmacy benefit manager’s portal.
· Identify and engage appropriate vendors throughout the claim process to support timely and cost-effective resolution.
· Maintain accurate, timely documentation of all communications and actions taken in the claim management system, adhering to bifurcation of benefit and liability files.
· Set and work daily diaries to ensure timely follow-up on all open, active claims.
· Draft claim correspondence for appropriate review and approval, including but not limited to denial letters, benefit extensions, continuation and suspension of benefits notices, and guidance letters.
· Prepare accurate and timely wage loss forms; submit to designated client contact(s) for processing and to the Providence accounting department for claim tracking.
· Maintain proactive, regular contact with clients, claimants (welfare calls), and medical providers throughout the life of the claim; respond to all parties, including management, in a timely manner consistent with the situation and established expectations.
· Present claims during client claim reviews and engage in discussion regarding claims, reserves, and action plans.
· May present and negotiate settlements with claimants and/or their attorneys.
· Participate in the after-hours on-call rotation (approximately three times per year).
· Provide PTO coverage for other IBCs as scheduled and directed.
· Assist with additional duties and projects as assigned.
Authorized Interpreters Only
The following function applies only to employees who have been designated as authorized interpreters. This designation is not a standard expectation of the Injury Benefit Coordinator role.
· Interpret between English-speaking employees and Spanish-speaking callers as requested.
Competencies
To perform this job successfully, an individual should demonstrate the following competencies:
Achievement Focus – Measures performance against a standard of excellence; recognizes and acts on opportunities; demonstrates persistence and overcomes obstacles to achieve claim and client outcomes.
Adaptability – Adjusts to changes in the work environment; manages competing demands; handles frequent change, delays, or unexpected events with flexibility and a solutions-oriented approach.
Analytical Thinking – Collects and researches data; uses sound judgment and experience to complement information; draws valid conclusions to support claim decisions, reserve-setting, and coverage determinations.
Business Acumen – Understands the business implications of the role, including how individual performance affects team outcomes, client relationships, and organizational goals.
Communications – Expresses ideas clearly in both verbal and written form; listens actively; keeps others appropriately informed; drafts professional correspondence including letters, emails, and claim documentation; selects the most effective communication method for each situation.
Conflict Resolution – Maintains objectivity and professionalism in difficult situations; keeps emotions under control; uses effective communication and negotiation skills to resolve concerns constructively, including interactions with claimants, attorneys, and clients.
Continuous Learning – Seeks feedback and pursues opportunities to build knowledge and skills; proactively adapts to process and changes in regulations, client protocols, and industry best practices; shares expertise with team members.
Customer Service – Responds promptly and professionally to claimants, clients, and colleagues; demonstrates compassion, concern, and respect in all communication with injured workers; manages difficult or emotional situations with empathy and composure.
Dependability – Follows instructions and responds to management direction; takes responsibility for own actions; completes tasks and diaries on time; communicates proactively if assistance is needed before a deadline is missed.
Ethics & Integrity – Treats others with respect; works with honesty and sound principles; upholds organizational values; maintains confidentiality in accordance with HIPAA and applicable regulations.
Initiative – Proactively manages claims without waiting for direction; volunteers assistance as workload permits; pursues self-development and seeks to continuously improve claim outcomes.
Job Knowledge – Demonstrates competency in required job skills and claim handling guidelines; applies new knowledge effectively; understands ERISA, client Work Injury Benefit Plans, and how the role connects to broader team and client relationship.
Judgment – Exhibits sound and accurate judgment; supports conclusions with clear reasoning; makes timely decisions on coverage, reserves, and claim direction; involves appropriate parties when needed.
Planning & Organizing – Prioritizes work activities effectively; manages time and diary systems efficiently across a multi-client workload; sets goals and maintains appropriate follow-up to ensure nothing is missed.
Problem Solving – Gathers and analyzes information skillfully, identifies and resolves claim issues in a timely manner; applies reason and professionalism in emotionally charged or legally sensitive situations.
Quality & Accuracy – Demonstrates thoroughness and attention to detail in all documentation, correspondence, and benefit determinations; monitors own work for accuracy; applies feedback to continuously improve performance.
Teamwork & Cooperation – Works collaboratively with team members; offers assistance willingly; contributes to a positive team environment; supports shared goals and the success of others.
Use of Technology – Demonstrates proficiency with required tools and systems; adapts to new technologies; uses technology to increase efficiency and productivity.
Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education and Experience
· High school diploma or general education diploma (GED) required.
· 2+ years of claims experience preferred.
· Formal claims training is helpful.
· Knowledge of medical terminology, workplace safety and/or medical cost management a plus.
Language Skills
· Ability to read, analyze and interpret plans, excess policies, client protocols, medical documentation and government regulations.
· Ability to write emails, reports, business correspondence, and claim documentation clearly and professionally.
· Ability to effectively present information and respond to questions from managers, clients, and customers.
Mathematical Skills
· Ability to calculate figures and amounts including wage loss, Department of Labor deadlines, percentages, mileage reimbursement, travel time and hours worked.
Computer Skills
· Proficiency in Microsoft Outlook and Word required; basic knowledge of Excel required.
· Ability to learn and utilize industry-specific claims management software.
· Experience with File Handler Enterprise a plus.
· Typing speed of 35+ WPM required.
Reasoning Ability
· Ability to define problems, collect data, establish facts and draw valid conclusions.
· Ability to interpret instructions provided in written, verbal, or other formats.
Work Conditions
The following are representative of the physical and environmental demands of this role. Reasonable accommodations may be made for individuals with disabilities.
· Monday – Friday, hybrid schedule; 37.5 – 40 hours per week. May occasionally work evenings or weekends based on business need, with prior manager approval.
· Primarily stationary role; must be able to remain at a workstation for extended periods, with standard breaks.
· Occasionally moves about the office to access file cabinets, equipment, or other workspaces.
· Must be able to operate standard office equipment including computer, keyboard, phone, and copier.
· Work environment has low to moderate noise and/or distraction levels.
· Occasionally lifts or moves up to 10 pounds.
· Travel locally and out of state as needed for client site visits, conferences, training, and meetings.
o Standard mode of travel is determined first by efficiency. Travel distances greater than five (5) hours are traveled by plane; employees may elect to drive or fly for distances under five (5) hours. Travel may consist of overnight stay(s), typically two (2) to five (5) times per year, depending on business needs.
Pay: From $20.00 per hour
Benefits:
- 401(k)
- 401(k) 3% Match
- Employee assistance program
- Flexible schedule
- Flexible spending account
- Health insurance
- Life insurance
- Paid time off
- Retirement plan
- Vision insurance
Work Location: In person
