Third-Party Claims Administration Services

The Vendor is required to provide professional claims administration services for the City's self-funded Workers' Compensation, Property, Liability Program, and Nurse Case Management Services.
- Provide a business partner beyond just traditional claims processing and administration.
- The City seeks someone to function as an extension of the Risk Management staff by active management (i.e., care coordination with the dedicated adjuster, claims assistant and providers, management of high dollar claims, data analytics and business intelligence) of the Program compared to a traditional administrator of claims.
- Provide excellent customer service.
- Flexible and Accurate Claims Processing. The City expects that unusual or large claims meeting certain criteria are reviewed by the third-party administrator to ensure they are billed accurately. Open claims promptly.
- Network Access and Direct Contracting
- Proactive Management of Care through Health Advocacy. The City’s goal for its employees is make their health a priority and keep healthcare as simple as possible
- Maintain comprehensive, effective communication among claims administrator, claimant, and City.
- The City’s program structure, list of policies, loss summary reports, and a list of treating providers have been provided for reference.
- The City chooses to carry WC coverage which provides lost wages and medical benefits to employees injured on the job.
- The City maintains a $1,250,000 self-insured retention on the workers’ compensation program and $500,000 retention on the casualty program. City purchases excess liability insurance above and beyond underlying policy limits.
- Check run days are Monday through Friday. In the event of a City holiday, the check run day is the prior business day.
- The Claims Administrator provides all information needed to process checks and verify payments, including check register, positive pay file, vouchers, and supporting documentation, explanation of payment, and explanation of bill review.
- The current Administrator has a dedicated senior claims adjustor and liability claims adjustor. The administrator also provides a claims assistant whose dedication to the City is 40% of their workload. Any alternative staffing arrangements based on the qualifications and capabilities of their staff, are subject to City review and approval.
- Process all worker’s compensation, general liability, automobile liability, and third-party property claims.
- The City handles their first party property losses and subrogation in-house, and manages legal engagement only for both workers’ compensation and liability claims.
- To make effective decisions in managing the City’s Program, it is imperative our partner be able to allow for access to the clinical notes, admissions, etc. for care coordination and case management.
- Assists employees during times of complex illness or injury to navigate the workers compensation system. Effectively manage issues to eliminate employee stress or inability to manage the system.
- Reviews daily report to appropriately identify individuals who would benefit from onsite assessment, care coordination and make appropriate referrals to population health programs/specialty programs. Review claim detail reports to identify unusual utilization patterns and solutions to mitigate risk.
- Review monthly employees’ who incurred fees are $50,000 or higher. Identify plan employees plan for onsite and follow for potential risk management.