• Claims Analyst

    Job Location US-AZ-Phoenix
    Department
    Store Support Staff (Corporate/Field Support)
    Position Type
    Full-Time
    Requisition ID
    52510
  • Overview

     

    As a Claims Analyst you will work within the Claims team in a rapidly growing, dynamic company to assist with the development and execution of solutions and programs that reduce claim frequency, mitigate claim severity, and drive positive claim outcomes. This position will direct our third-party administrator (TPA) toward case resolution.  The Senior Claims Analyst must possess a well-developed technical knowledge of standard concepts, practices, procedures, laws and regulations within Workers Compensation and related services. This position also requires excellent interpersonal and time management skills and a high degree of sound judgment, discretion, and initiative.

    Essential Functions

    • Direct claims management program to ensure thorough investigation, processing, and setting of proper claim reserves by the TPA for the Workers Compensation program.
      • Develop strategies to handle specific cases in consultation with the appropriate parties.
      • Assist with recommendations, updates, and implementation of workers’ compensation policies and procedures.
      • Provide and coordinate internal training as needed.
      • Independently respond to and resolve difficult and sensitive inquiries and complaints; evaluate problems and take appropriate action to resolve issues/concerns.
      • Monitor critical claims for timely reporting and adherence to agreed upon resolution plan by reviewing claim notes and conducting follow up meetings with claim adjuster, nurse case manager, and outside counsel
    • Direct Workers Compensation TPAs and vendors
      • Review, recommend and assist adjusters with claim negotiations and settlements
      • Review support of established reserves for accuracy of anticipated costs on critical or 'red flag' cases.
      • Review and authorize approval of reserve thresholds, settlement values, subrogation efforts, surviellance and investigation strategies.
      • Identify, evaluate and assess probability and severity of losses on critical, aged and 'red flag' claims. Develop, implement, and monitor cost containment strategies to prevent and minimize losses.
      • Complete required reports and records; authorize payment on miscellaneous bills as needed.
    • Monitor TPA performance, ensure commitments of contract, and assist in establishing expectations and metrics.
      • Maintain diary of settlement authorization approvals, managed care requests and claim investigation efforts for timely follow up and results.
      • Ensure TPA special account instructions and guidelines are followed at all times.
    • Conduct claim file reviews and audits on claims strategy, case valuation and adherence to the special account instructions.
      • Schedule and coordinate quarterly TPA claim reviews
      • Assist Claims Team management in selecting matters for claim review using innovative analysis.
      • Provide ongoing oversight and critical management of claims programs
      • Document and present status updates to Claims Team management at regularly scheduled intervals
      • Maintain diary of adjuster expectations on all claim reviews to ensure timely delivery of action items
      • Maintain assigned claims data accurately in the risk management information system

     

    • Provide training and guidance on best practices for managing Workers Compensation processes to include adherence to state laws.
      • Assist Claims and Safety teams in building educational material and platform for all team members
      • Lead or participate in discussions regarding workers’ compensation issues; represent the Claims Team.
      • Assist Claims Team management with oversight and ensure an efficient records maintenance system for workers’ compensation claims and related information, data and activities.
    • Manage and coordinate the return to work program for injured team members.
      • Contact injured team members to discuss their ability to return to work
      • Negotiate and coordinate prompt return to work between stores and team members.
      • Partner with Claims Team management to analyze and evaluate results of Return To Work program, Modified Duty program and related services, and present findings to Claims Team management and business partners
      • Serve as liaison between third-party adjusters, stores, and team members to ensure prompt addition to/removal from the Modified Duty program
      • Monitor team members on the modified duty program to ensure that stores and team members are following all applicable policies, procedures, and practices.
      • Partner with Claims Team management to develop and analyze reporting metrics related to modified duty, review progress on developed metrics, and identify areas of opportunity.
      • Present cases at regularly scheduled Work Restriction Review Committee meetings
      • Routinely evaluate and analyze the Modified Duty program, consistently updating and improving work flows that will drive program growth and success.
      • Partner with HR on leaves of absence and restrictions to ensure ADA compliance
    • Run and analyze reports on monthly claim statistics for Claims Team and other business partners, including but not limited to Safety, Legal, and Operations
      • Work cross functionally to provide support by analyzing data, sharing trends, giving recommendations, and developing solutions that positively impact claims
      • Provide timely responses to requests for information from all partners and stakeholders
      • Analyze reports for trends and provide findings and recommendations to Claims Team management as appropriate.
      • Work closely with business partners to review all current programs and provide analysis.
    • Establish and maintain cooperative relationships with all partners and stakeholders
    • Stay abreast of trends and innovations in the field of workers’ compensation claim administration and keep current on legislative and regulatory issues at the state and federal level.

    Perform additional duties as requested by management. Assigned responsibilities and duties may vary based upon department growth and evolving operations.

    Knowledge, Skills, Abilities and Physical Requirements

    • Excellent written and verbal communication skills
    • High level of discretion and confidentiality
    • Thorough working knowledge of procedural requirements for managing worker’s compensation claims and identifying claims that present critical exposure risk
    • Thorough working knowledge of best practices for return-to-work and modified duty programs for injured workers
    • General understanding of the basic laws and regulations governing the administration and reporting of worker’s compensation claims and modified duty programs for injured workers
    • General understanding of the Americans with Disabilities Act preferred but not required
    • Knowledge of basic medical terminology and procedures involved in work-related injuries and occupational diseases
    • Ability to compile, prepare, and organize data
    • Ability to communicate professionally and effectively, both orally and in writing
    • Ability to manage and coordinate with Sprouts team members at all levels, as well as with external partners, including but not limited to TPAs, medical providers, other vendors, and outside counsel
    • Ability to multi-task and coordinate information and resources efficiently and effectively
    • Proficiency in using computer systems and the listed software applications associated with performance of assigned work.
    • Basic problem solving skills associated with software application.

    Software applications

    • Efficient with MS Office software products (Word, Excel, Power Point, and Outlook)
    • Able to quickly learn various TPA and insurer systems as well as risk management information systems.

    Qualifications, Training and/or Education

    Minimum qualifications include:

    • Bachelor’s Degree from an accredited college or university with course concentration in risk management, legal studies, or claims adjudication; or
    • Associate degree from an accredited college and/or insurance industry accredited courses or certificates of completion in workers’ compensation claim adjudication, legal liability, and specialized training in workers’ compensation claim administration.
    • 5 years experience working with a Third Party Workers Compensation Claims Administrator on Indemnity, Attorney Represented and Medical Only claims. 
    • Claims Adjuster Designation (Current or Continuing Education Hours) is preferred.

    Benefits

    In addition to a rewarding career, Sprouts offers a comprehensive program to help support you and your family. These programs include:

    • Competitive pay
    • Opportunities for career growth
    • 15% discount for you and one other family member in your household on all purchases made at Sprouts
    • Flexible schedules
    • Employee Assistance Program (EAP)

    Eligibility requirements may apply for the following benefits:

    • 401(K) Retirement savings plan with a generous company match
    • Affordable benefit coverage, including medical, dental vision
    • Pre-tax Flexible Spending Accounts for healthcare and dependent care
    • Company paid life insurance and short-term disability coverage

    Why Sprouts

    Grow with us!

    If you have a passion for inspiring people and a flair for fresh food, consider applying for a job at Sprouts! With a focus on customer service, our neighborhood grocery stores offer high-quality, farm fresh produce, natural meats, plenty of scoop-your-own bulk goods and much more in a fun, friendly, old-fashioned farmer’s market setting.  Come grow your career in healthy living with a fast-paced, rapidly growing company and teams that pride themselves on empowering others along their journey.

     

     

    The above statements are intended to describe the general nature and level of the work being performed by people assigned to this work. This is not an exhaustive list of all duties, responsibilities, and requirements. Sprouts’ management reserves the right to amend and change duties, responsibilities, and requirements to meet business and organizational needs as necessary.

     

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