Senior Workers Compensation Compliance Officer
Typical tasks include determine liability, initiate and control delivery of accurate and timely compensation, medical and rehabilitation benefits to qualified injured workers as prescribed by law and within State Fund's guidelines and procedures; determine accurate and adequate estimates on assigned claims; review and analyze case documentation and plan proactive case management strategies; prepare case resumes for policyholders; calculate and negotiate settlements; write correspondence and reports; provide and coordinate all medical and vocational rehabilitation services to the catastrophically injured worker; plan, coordinate and evaluate claims technical training; lead training program project teams;?develop, implement, coordinate and maintain new medical cost containment projects throughout the districts; track regional cost trends on implemented projects; analyze and evaluate analyst service requests for the improvement of data processing systems used in State Fund's claims adjustment functions; implement the findings and recommendations to improve claims data systems; develop and implement training for systems users; develop projects that impact State Fund's claims case management procedures; revise claims manuals and claims forms; identify, evaluate and report reinsurance claims; conduct excess insurance audits and report on the status of excess insurance claims; develop and negotiate structured settlements.
Adjuster handling workers compensation claims from the Uninsured Employers Benefits Trust Fund (UEBTF) when illegally uninsured employers fail to pay workers' compensation benefits awarded to their injured employees by the Workers' Compensation Appeals Board. Complete a thorough investigation on all disability and selected non-disability claims to determine if a claim is compensable or not. Identify work capabilities to reduce Total Temporary Disability and facilitate early return to work and pro-actively pursue modified duties and release to full duties. Ensure injured workers receives appropriate medical treatment until discharged from care or maximum medical improvement and confirm all treatment is for conditions that are medically caused by the work injury to achieve cost effective quality claim settlements on claims. Control/contain medical costs, including drug regimens and monitor treatment plans to achieve full and final resolution on each assigned claim. Reduce claim cycle time and resolve claims at earliest opportunity by working with state agency personnel in getting their injured workers back to gainful employment, and ensuring timely and accurate liability decisions.
Leads audits of workers' compensation insurers, self-insured employers, and third-party administrators to assure compliance with the law and regulations of the Administrative Director; acts as lead person for compliance officers, reviewing audit worksheets and proposed assessments and providing the WCCO with on-the-job training and advice on audit guidelines and procedures; identifies violations, determines administrative penalties, explains audit findings, prepares and issues preliminary reports and notices of penalty assessments. Conducting monthly workshops to Claims Administrators and the public. Lead Utilization Review investigations in accordance with LC 4610, 9792.6 - 9792.12.
Conducts post-audit conferences following the three phases of the audits and UR investigations, makes decisions regarding disputed penalties and mitigation involving violations; meet with audit subjects and legal representatives to explain the bases for decisions in disputed penalties, issues final audit reports, Prepares accurate summaries of disputed audit issues and penalties, including recommended decisions and the reasons for the decisions, for submission for approval to the Administrative Director on appealed audit penalties; testifies at hearings and judicial proceedings. Provides complaint analysis as needed.
Reviews complex files, performs complex earning calculations, review and responds to complex rebuttals, perform detailed analysis of liability determinations, perform permanent disability ratings. Assists with the annual calculation of the audit score for PAR and FCA and maintaining the audit glossary for all audit staff.
Represents the Division in meetings and conferences and makes presentations. Interact with injured workers and vendors in relation to complaints and indemnity audit compliance.
Conducts special projects and performs other duties as required. Assisting with data collection on the Annual Audit Report.
Knowledge of specialized and complex program auditing practices and procedures; principles and theories of administrative law and judicial review of administrative actions; legal terms and forms in common use.
Ability to conduct fair and impartial hearings in a manner that will obtain all pertinent evidence; make accurate summaries of evidence, prepare reasons for decisions, and make findings based on such facts.
Ability to work independently with minimum guidance
Willingness to travel in and out of state and work irregular hours, tact and impartiality.
Possession of keen organization and time management skills
Possession of a valid California driver's license.
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