Evaluates new and on-going claims to determine compensability and liability, giving consideration to contract provisions, disability management duration contract guidelines, medical evidence and vocational evidence. Investigates questionable claims. Determines needs for additional medical information. Determine appropriate benefit calculations and payments. Performs reviews to verify initial and continued existence of a disabling condition. Responds to telephone and written inquiries from claimants, attorneys, physicians and policyholders within statutory requirements. Identifies and forwards claims to specialized internal and external resources in areas such as medical exams, rehabilitation, investigations, subrogation and subsequent injury. Track time frames as mandated by statute and regulation. Respond to correspondence to include litigation compliance with decisions & orders. This level is responsible for independently reviewing simple to complex claims for adjudication purposes. Refers more complex claims to higher levels for review and direction. This level is responsible for administering complex including catastrophic and death claims Claims handle will include claims in access and permanent total disability Submit for COLA reimbursement and SIF
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