Sr. Workers' Compensation Resolution Specialist (Hybrid)

The Senior Workers' Compensation Resolution Specialist is responsible for managing and resolving complex workers' compensation claims with a strategic focus on mitigating exposure and ensuring fair and cost-effective resolutions for all parties. This role involves direct handling of settlement negotiations, developing settlement strategies, and collaborating with adjusters, specialists, legal teams, and other stakeholders to ensure claims are resolved in a timely and efficient manner that benefits the injured worker, the employer and the PRISM Programs in a fair and equitable approach. Additionally, the Resolution Specialist will be responsible for providing training and guidance to staff and members on claims processes, best practices, and strategies for reducing overall claims costs.

Requirements

Qualifications:

Education: Bachelor’s degree or equivalent workers’ compensation claims handling and negotiation experience. Certification in claims management or a related area is a plus.

Experience:

• Minimum of 5-7 years of experience in workers' compensation claims handling, with at least 3 years focused on settlements or complex claims.
• Proven track record in settling and negotiating claims and navigating litigation processes.
• Familiarity with California Labor Code and case law as it pertains to workers compensation.

Licenses/Certifications:

• Self-Insurance Plans certificate or ability to obtain within first six months of employment.
• Workers’ Compensation Claims Administration (WCCA) certification is a plus.
• Workers’ Compensation Claims Professional (WCCP) certification is a plus.

Skills and Competencies:

• Analytical Skills: Ability to analyze complex information, identify key issues, and make informed decisions.
• Communication Skills: Excellent written and verbal communication skills, with the ability to convey complex information clearly to various stakeholders.
• Negotiation Skills: Strong negotiation and settlement skills, with the ability to achieve favorable, fair and equitable outcomes.
• Legal Knowledge: In-depth understanding of California workers' compensation laws, regulations, and legal procedures.
• Interpersonal Skills: Ability to build and maintain relationships with internal and external parties.
• Organizational Skills: Exceptional time management and organizational abilities, capable of handling multiple claims simultaneously.
• Problem-Solving: Strong critical thinking and problem-solving abilities, with a focus on innovative solutions.
• Leadership Experience: Experience mentoring and training claims professionals.
• Strategic Thinking: Ability to develop and implement long-term strategies to mitigate claims costs and improve claims outcomes.
• Industry Knowledge: Up-to-date knowledge of industry trends, emerging risks, and best practices in large loss claims management
• Technical Skills: Proficiency in claims management software and Microsoft Office Suite

Work Environment:

• This role may be eligible for hybrid work model consisting of remote work and in-person work in our Folsom office, as well as occasional to frequent travel to attend hearings, mediations, or on-site settlement conferences as required.

Key Responsibilities:

Claims Management and Resolution

• Evaluate Complex Claims: Assess cases thoroughly to identify potential risks and develop settlement strategies that are cost-effective and legally sound.
• Settlement Negotiations: Lead negotiations with injured employees, attorneys, claims administrators, employers and other representatives to achieve fair and efficient settlement agreements.
• Claim Investigations: Conduct thorough analysis on claims, reviewing medical records, legal documents, and other relevant materials to make informed settlement decisions.
• Liaison Role: Serve as a liaison between various stakeholders, including injured employees, attorneys, adjusters, and other claims professionals, to facilitate clear communication and expedite the resolution process.
• Documentation and Compliance: Ensure all settlements are documented accurately, maintaining compliance with state and federal laws and organizational guidelines.

Exposure Mitigation

• Risk Analysis and Strategy Development: Regularly review claims to identify early intervention opportunities and implement strategies to reduce financial exposure.
• Financial Analysis: Evaluate the financial impact of claims and settlements, including future medical expenses and indemnity, to ensure reserves are accurately set per OSIP standards.
• Loss Prevention Initiatives: Partner with the risk management team to identify trends and contribute to initiatives aimed at reducing claim frequency and severity.

Training and Development

• Staff Training: Develop and deliver training programs for the TPA Claims Adjusters, PRISM Specialists and other relevant staff on claims management, settlement negotiation and best practices.
• Member Training and Education: Provide guidance and training to members (e.g., employers or stakeholders within the workers' compensation program) on handling claims, preventing fraudulent claims, and mitigating workers' compensation costs by early resolution and settlement.
• Resource Development: Create training materials, guides, and presentations on various topics related to workers' compensation claims, settlement processes and risk management.
• Mentorship: Mentor and support new PRISM staff and when applicable, TPA Claims Adjusters in handling complex cases, sharing insights from more challenging claims and improving overall settlement skills within the team.

Reporting and Analytics

• Claims Reporting: Generate and analyze settlement reports to track and monitor performance metrics, settlement trends and claims outcomes.
• Trend Analysis: Identify patterns in claims that contribute to cost drivers and recommend proactive measures to reduce long-term claims liabilities.
• Management Reports: Prepare monthly and quarterly reports for senior management that detail claim settlements, cost savings achieved, and strategic initiatives undertaken to mitigate exposure.
• Continuous Improvement: Use analytics to identify areas for process improvement within claims handling, settlement negotiation and staff training practices.

We are seeking candidates who can fulfill this position through a hybrid work model consisting of mostly remote work with some in-person work in our Folsom office.

Physical Requirements

Physical requirements of this position typically include: reaching, grasping, talking, hearing, seeing, repetitive motions, exerting up to 20 pounds of force occasionally and/or up to 10 pounds of force frequently, and/or negligible amount of force constantly to move. Some travel is required.