Claims Investigator - Toronto, Canada - Workplace Safety and Insurance Board

Workplace Safety and Insurance Board

Verified Company

Toronto, Canada

2 weeks ago

Posted by:

Sophia Lee

beBee Recruiter

Description

Manage caseload of new and ongoing investigations and conduct claims investigations enquiries where complex entitlement issues cannot be resolved by eligibility adjudicators, case managers and appeals resolution officers (ARO) through conventional claims enquiry methods.

Determine and secure all critical information needed to support a decision and help resolve issues in dispute. Prepare and author detailed investigation reports and/or memos to facilitate the decision making process.

Major Duties & Responsibilities
Plan, manage and conduct claims investigation throughout the province to various locations such as work sites (industrial, construction, commercial), residences, medical offices, hospitals, and agencies for interviews, to accommodate the availability of the parties involved by:

Reviewing claim files to determine if the referral meets the criteria for an investigation;
Ensuring all information needed to proceed with the investigation is available and current;
Identifying and obtaining required information, documents or other associated claims prior to commencing the investigation;
Identifying any other issues that require resolution prior to or during an investigation and taking appropriate action;
Case conferencing files, as needed, with case owners, managers, etc.
Recognizing and prioritizing claims within the assigned caseload based on the urgency and specific issues that need to be addressed;
Scheduling appointments with workplace parties that maximize efficiency taking into consideration geographic location and related travel requirements;
Interviewing workers, employers, treating physicians, specialists, agencies, coworkers, representatives including lawyers, in person or via telephone as required, to gather information and evidence through statements of fact;
Where necessary, examining medical records, financial statements and other official records or supporting documents;
Obtaining detailed job descriptions and physical demands information as required;
Organizing and analyzing information and documents following the interviews, and ensuring accuracy and completeness, and acting upon any discrepancies in order to resolve issues.

Determine and secure all critical information needed to support a decision and help resolve issues in dispute including:

Identifying issues and determining what information is required to resolve the case, and how best to obtain it;
Analyzing the available information through comprehensive file review to determine the best approach and methodology;
Recognizing the need for other specialist services as required and making appropriate recommendations to the decision maker.

Report the results of investigations by:

Ensuring the investigation report contains the relevant information, additional issues identified and resolved to enable the case owner or referring party to make a decision or take appropriate action;
Reporting any violations of the OH&SA to the case owner as appropriate;
Reporting any noted employer classification issues to the case owner regarding referrals to the Employer Service Centre;
Reporting on possible fraudulent activities and making recommendations regarding referrals to Regulatory Services Division.

Interact with internal and external clients to provide quality service and support by:

Providing information and advice to workplace parties regarding reporting obligations, accident prevention, RTW obligations and general revenue issues;
Building constructive and effective relationships with workplaces, service delivery teams, agencies and health care providers;
Perform other related duties as assigned or required.

Job Requirements
Education

Postsecondary diploma up to two years in protection security & investigation, or private investigation, or business administration, or legal studies.

Experience

Three years prior experience in investigations.

Our commitment to equity, diversity and inclusion
We respect and value the diversity of our people. We strive to create an environment where employees can be themselves and where our differences are celebrated.

The WSIB is committed to being accessible and inclusive, and following barrier-free and accessible employment practices in compliance with the Accessibility for Ontarians with Disabilities Act (AODA).

Should you require accommodation through any stage of the recruitment process, please let us know when we contact you and we will work with you to meet your needs.

Disclosing conflicts of interest
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