The ESIS Claims Compliance Specialist supports compliance and operational excellence within the claims department, with a strong focus on workers’ compensation claims. This role is responsible for preparing annual reports for self-insured accounts, responding to the Self-Insured Audit Committee, supporting special projects, preparing files for carrier and state audits, and providing general administrative support. The specialist also implements quality plans, monitors results, and recommends corrective actions as needed.
This position reports to and receives direction from the Claims Manager.
This is a hybrid position, with three days per week in the office.
Duties and Responsibilities include, but are not limited to:
- Prepare annual reports for self-insured accounts, including claims data and financial information, for submission to California’s DIR Office of Self-Insurance Plans (OSIP) by March 1 each year. This includes the annual report, actuarial study, and audited financials.
- Review and prepare files for PAR audits to ensure timely and accurate payments, proper documentation, and correct wage calculations.
- Review and prepare files for carrier audits to ensure compliance with carrier guidelines.
- Collaborate with the Claims Manager to improve Quality Review (QR) scores, including auditing individual files for compliance with QR guidelines.
- Participate in special projects as assigned.
- Assist in the preparation of Claims Loss Reports (CLR).
- Complete Executive Loss Summary (ELS) reports, maintain a log of all reports due, and ensure timely compliance.
- Support the training of new hires and provide ongoing training for existing employees, working with the Learning & Development team and in-house trainers to develop training schedules.
- Review claim progress and status with the Team Leader, discuss issues, and recommend corrective actions.
- Prepare and submit reports on unusual or potentially adverse exposures to the Team Leader.
- Assist in penalty reduction initiatives.
- Support the Team Leader in developing process improvements and enhanced methods for claims handling.
- Assist the Claims Vice President, Claims Manager, Team Leaders, and Claims Handlers with special projects, including reserve analysis, account-specific projects, closing projects, and audits.
