Claims Management Specialist

Job Summary

We’re seeking a knowledgeable and proactive Claims Management Specialist to join our Employee Health Services team. Reporting to the Manager, this role serves as the subject matter expert in occupational illness, injury, and claims management.

You’ll lead efforts to support early and safe return-to-work strategies, ensure compliance with legislative requirements, and manage all employer documentation related to appeals and tribunals. In addition, you’ll provide health coaching and connect employees with wellness resources to promote recovery and long-term well-being.

Duties and Responsibilities

• Manage a caseload of complex occupational disability and return-to-work claims
• Develop and implement return-to-work plans addressing barriers to rehabilitation and return to work
• Liaise with third-party providers, employees, unions, and management
• Liaise with HR to discuss, clarify and gather appropriate details of workplace issues impacting absence
• Participate in interdisciplinary claims meetings for file reviews
• Ensure adherence to policy, procedure, and best practice in case management
• Ensure adherence to legislation for timely filing of Form 7 reports and Ministry of Labour reporting as required
• Identify trends and recommend improvements to WSIB case management processes
• Monthly review of claim cost statements; conduct regular claim audits to guide cost containment
• Participate in actuarial review for the purpose of projected future funding and costs
• Assist with appeals, reviewing decisions and providing recommendations based on thorough analysis and understanding of individual case details
• Assist in grievance preparation and documentation
• Maintain the confidentiality of employee’s health files within the City’s electronic records management system
• Ensure timely, accurate and thorough documentation
• Navigate systems and portals to access data for reporting purposes
• Ensure compliance with Human Rights Code, absence policies and practices, Occupational Health and Safety Act, WSIB and various collective agreements.  Comply with relevant City policies
• Participate on projects/initiatives within the team as required

Skills and Qualifications

• Post secondary education in Human Resources, allied/healthcare related field, or Occupational Health and Safety combined with three years of direct experience with claims management, return to work programs and WSIB; specifically mental stress injuries.
• Certification in disability management, WSIB case management, return to work coordinator, or working towards certification, is preferred
• Experience working with first responders is a definite asset;
• Experience working in a unionized environment is an asset;
• Broad experience in policy and legislation interpretation, customer service, problem solving and conflict resolution skills;
• Strong time management and organizational skills; attention to detail to manage work, competing deadlines and sensitive projects;
• Team player, able to work effectively with all levels of the organization;
• Advanced computer skills, and knowledge and expertise in Microsoft Office and medical documentation systems;
• Superior interpersonal and communication skills (written, verbal and presentation);
• Demonstrates discretion, confidentiality, sound judgment and sensitivity;
• Strong problem solving and critical thinking skills