If you think all the claims people are located in the claims office, you would be in the large majority of the risk and insurance world, and you would be wrong. There are various types of claims people in support and management roles at the insurers and the third party administrators (TPA) who have a major impact on the success of your workers’ compensation program. Here is a brief synopsis of the other claims people you may never hear about.
Account Administrator/Risk Technical Adviser
This position was previously known as the “home office examiner,” but insurance companies and TPAs have renamed the claims position in several different ways. In some companies it will still be referred to as the “home office examiner,” but other names like “account administrator” and “risk technical adviser” are being used to describe the position.
The home office examiner/account administrator/risk technical adviser is a person with a tremendous amount of claims knowledge, claims experience and “know how” who oversees the catastrophic injury claims — the more difficult and expensive claims. The home office examiner’s role is to be a “second set of eyes” on the file. The home office examiner will review the catastrophic injury claims to be sure the medical management, disability management and resolution of the file is handled in the best interest of the insured and the insurance company.
The home office examiner will provide direction and supervision whenever the claims office asks for guidance. The home office examiner will also intervene if the course of the claim is not what it should be. At TPA’s this role will also encompass verifying the claim offices are complying with all the requirements of the client.
The account manager for the insurance company, or the TPA, is a hybrid role between a claims person and a salesperson. The account manager acts as a liaison between the employer, the insurer and the TPA, when a TPA is handling the claims.
Often the account manager is a direct contact for the employer’s risk manager or claims coordinator with the intent of resolving all insurance program related problems and answering all questions about the insurance program. The account manager is the go-to person to resolve any issues that arise whether it is compliance by the claims office with the service standards, the deletion or adding of new locations to the insurance program, the resolution of questions about the program or the corrections of any errors or mistakes in the data management.
The role of the nurse case manager is to provide medical expertise beyond the knowledge the adjuster will acquire from reviewing medical reports and medical histories. The nurse case manager is a license practical nurse or a registered nurse who has the nursing degree plus years of experience in the medical field.
When the nature of the injury is severe and the adjuster wants medical management of the claim to be provided, the nurse case manager is assigned to the claim file. The nurse case manager will coordinate and facilitate the health care services provided to the injured employee to assist the employee in achieving the best recovery possible.
The nurse case manager will provide to the adjuster a patient assessment and a treatment plan that has been coordinated with the medical provider. The implementation of the treatment plan and the execution of the treatment plan are part of the nurse case manager‘s responsibilities.
Not only is the nurse case manager an adviser to the adjuster but also a trained medical expert who can answer the medical questions the injured employee may have between medical provider visits.
The adjuster-in-charge, also known as a “resident adjuster,” is often used when a large employer wants an on-site adjuster to handle their workers’ comp claims. This facilitates the immediate reporting and the immediate investigation and handling of each new injury claim. The adjuster-in-charge is an employee of the insurer or TPA, but is domiciled at the employer’s location or in a one-person office near the employer.
The adjuster-in-charge will be an experienced adjuster who is capable of working independently from an on-site supervisor. The workload of an adjuster-in-charge will normally include a mix bag of simple workers’ comp claims to the most severe claims. The position often entails the adjuster having to do everything from taking in the new assignments to the closing of the claim files.
When an insurer or TPA has a large number of claims offices, the supervision of those claims office is often broken down into regions of the country. The regional manager is responsible for the services provided by the claims offices in the territory or region. The regional manager provides the direction to the claims offices and provides the home office management with a greater degree of control.
Vice President of Claim
At the top of the claims hierarchy is the vice president of claims. The responsibilities of the vice president of claims includes the planning, organizing, directing and controlling of all the activities of the claims offices and claims regions. The vice president of claims is also responsible for the performance of the claims offices, the profitability of the claims offices and the claim services provided.
The various support roles outside of the workers’ comp claims office are often the keys to the success of the claims program. Whether it is the claims examiner keeping the high dollar files on track, the account manager resolving all the issues that come up, the nurse case manager providing the necessary medical expertise or the senior management overseeing the claims program, they all can have a positive influence on making your workers’ comp insurance program successful.
Author Rebecca Shafer, J.D, President, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact: RShafer@ReduceYourWorkersComp.com .
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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers’ comp issues.
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