Claims Consultant (Workers' Compensation)

CLAIMS CONSULTANT

POSITION DESCRIPTION

I. UNIT NAME: Claims & Risk Management

II. FLSA CLASSIFICATION: Exempt: Salaried

III. REPORTING RELATIONSHIPS:

• Reports to Senior Vice President, Claims and Risk Management
• Positions reporting to claims consultant: None

IV. POSITION SUMMARY:

The claims consultant will embody those behaviors, philosophies, and values which serve to uphold the ideals and enhance the image of Antum Risk. The claims consultant handles all claim types filed with Antum Risk with a total incurred exposure of $200,000 or less; claims exceeding that exposure, and all catastrophic claims, are referred to a claims consultant II or senior claims consultant. The claims consultant is responsible for the day-to-day handling of the claims assigned to their accounts, and for managing those claims to ensure high-quality service. The claims consultant contributes to an environment that fosters and encourages a team approach toward the accomplishment of Antum objectives, and trains and provides guidance to associates at or below the claims consultant level. The claims consultant participates in interdisciplinary monitoring and evaluation of the claims function. The claims consultant works regularly with information that is of a confidential nature and discretion and integrity are recognized requirements of the job.

V. QUALIFICATIONS:

EDUCATION: Bachelor’s degree preferred but not required.

EXPERIENCE: Minimum of two years workers’ compensation or related insurance claims handling experience.

LICENSE: South Carolina Workers’ Compensation Adjusters License

DESIGNATION: AIC designation or similar designation preferred but not required

SKILLS:

• Able to use computer applications
• Able to use office equipment

PHYSICAL:

• Able to work at a computer during most of a business day
• Must have reliable transportation
• Must have valid South Carolina driver’s license
• This position requires the individual to travel on Company Business as needed but less than 25% of the time

VI. FUNCTIONS:

A. Handles all claim types filed with Antum Risk with a total incurred exposure of $200,000 or less.

B. Responsible for ensuring CMS Section 111 Requirements are applied to assigned claims and reported to CMS via selected vendor.

C. Conducts investigations, file management, reserving, and payment of assigned claims in accordance with PHT procedures.

D. Ensures compliance daily with statutory and regulatory claims requirements.

E. Refers claims as needed to vendors for legal, medical, field case management, surveillance, independent medical examination and pharmacy/equipment management services.

F. Represents Antum Risk at mediations, informal conferences and hearings as necessary.

G. Monitors assigned claims for development in exposure and refers to a claims consultant II or senior claims consultant any claim whose total incurred exposure exceeds, or is reasonably expected to exceed, $200,000, and any claim that meets the definition of a catastrophic claim, upon identification.

H. Meets with claims coordinator at assigned member facilities at least annually.

I. Trains and provides guidance with the handling of claims to associates at or below the claims consultant level as necessary.

J. Assists the claims consultant II, senior claims consultant, and the Senior Vice President, Claims and Risk Management with special projects as necessary.

K. Ensures continuous improvement within the claims unit

L. Reports claims information to excess insurance carrier(s) as needed.

M. Provides reports on claims and activities to Senior Vice President, Claims and Risk Management.

N. Embraces the use of artificial intelligence and applies the tools approved by Antum Risk as fully as practicable within daily job duties to improve the accuracy, efficiency, and consistency of claims handling. Maintains the confidentiality of claim and member information in all such use, and retains responsibility for independent professional judgment on every claim decision.

O. Discharges all responsibilities inherent in and naturally flowing from the position description.

P. Performs other duties as assigned.

VII. ORGANIZATION-WIDE REQUIREMENTS:

• Maintains good working relationships with internal staff and external clients.
• Complies with all company policies, procedures, agreements, values, behaviors and outcomes.