Workers Compensation Claims Specialist OR Senior Specialist

This position may be filled at the Specialist or Sr. Specialist level, depending on selected candidates qualifications. The salary range is advertised broadly to reflect the two possible levels, and salary will be dependent on the selected candidates qualifications. 

Selected candidates will have the option to work full time in our Folsom office, or remotely from a home location within a commutable distance from our Folsom, CA office, or a hybrid of both options. Candidates must be able and willing to report in person to our Folsom location when required which is generally 2 to 3 times per month, but could change based on business needs. 

PRISM is a joint powers authority (JPA) that provides risk management and coverage programs for over 2,000 public entities throughout California.  Our organization is member driven meaning that our members have numerous opportunities available to participate in the governance of our JPA.

The Workers' Compensation Specialist/Senior Workers’ Compensation Specialist is responsible for managing a caseload of excess workers’ compensation claims, consisting of complex and catastrophic claims (future medical and possibly indemnity claims at the Specialist level) along with providing oversight of TPAs and claims processes in both our Primary Workers’ Compensation (PWC) and Excess Workers’ Compensation (EWC) Programs; reviewing and overseeing claims for appropriate medical care, reserves, reimbursement, reinsurance and resolution.

The responsibilities below will be performed at both the Specialist & Sr. Specialist level, but the complexity of the work will differ:

• Review all newly reported excess reportable claims.
• Review all incoming mail.
• Complete regular diary reviews of all claims within their respective caseloads.  This may include, but not limited to:
  • Review reserves to ensure the claim file is reserved in accordance with OSIP Regulations and most probable value of the claim.
  • Review the medical aspect of claims to ensure proper medical care is being provided.
  • Review claims for allocation/contribution potential.
  • Review subrogation efforts and provide authority regarding resolution when applicable. 
  • Review for recommendations for all aspects of the claim (e.g. reserving, next steps, medical treatment authorizations, resolution strategies, etc.). 
• Maintain a current diary.
• Report applicable claims to the reinsurance/excess partners at required intervals based upon the policy requirements.  This may include the initial reporting, subsequent reporting, interim collaboration and final reporting.
• Reconcile and approve all applicable excess reimbursements to the Members.
• Approve all associated reimbursement requests to the reinsurers as applicable when processing a Member reimbursement.
• Through the oversight of claims and collaboration with the members and TPAs, provide recommendations and strategies to mitigate the exposure and/or settle the claim.
• Review and approve all settlement authority requests in accordance with applicable policies, and seek excess/reinsurance approval when required.
• Assist PRISM members, TPA staff and legal representatives with discovery and settlement of claims; contact and discuss potential defenses and settlement strategies with member agency personnel, legal, settlement and claims representatives.
• Maintain a caseload of open excess reportable Indemnity and Future Medical claims on a regular diary in an electronic claim file environment.
• Provide oversight and influence on PWC claims, even those not yet excess reportable.
• Communicate member or TPA concerns, along with any proposed solutions, with their respective PRISM Supervisor.
• Attend and provide input for settlement conferences, defense counsel meetings and court hearings on cases within the scope of PRISM coverage.
• Review insurance policies, governing documents and program policy statements for applicability of coverage on specific claims.
• Present cases and settlement recommendations as well as program related matters and recommendations to the PWC and Claims Review Committees (CRC), and when applicable the Executive Committee.  
• Assist with preparation of the agenda for PWC and CRC Committees, and attend Board and Committee meetings as required.  This may include agenda write-ups for open or closed agenda items.
• Provide quality assurance by performing a liaison role with TPAs and members, conducting on-going field audits as well as online audits of TPAs in the PWC program.  Participate in regular file reviews; provide recommendations to management and governing committees on ways to improve claims services. 
• Participate in personal professional development, including legal case law updates, educational seminars and conferences.  
• Provide training to members and TPAs.  
• Participate in staff development, including mentoring new hires, promoted staff and others as requested by the Supervisor, Manager and/or Director.
• Analyze needs of members and connect them with the appropriate services to minimize their risk.  
• Travel for work functions as necessary.
• Support PRISM Core Values and PRISM Mission.
• Assist in completing organizational goals and objectives as outlined in the Strategic Plan, CEO Goals, etc.
• Lead with a strong customer service focus for both internal and external customers.
• Foster member relationships and assist members with any workers’ compensation claims and/or coverage issues.  
• Perform other duties as assigned.