Claims Specialist - Workers Compensation

Old Republic Commercial Risk; City of Albany (NY); On-site; USD 85,000 - 115,000; Full time

Job summary

Old Republic Commercial Risk is seeking a qualified Claims professional to independently investigate, evaluate, and resolve high-complexity Workers' Compensation claims. The role involves determining coverage, managing reserves, negotiating settlements, and coordinating with medical and litigation teams.

The ideal candidate has a Bachelor's degree and significant workers' comp experience, with AIC designation or equivalent preferred. Travel up to 10% may be required.

Qualifications

• Bachelor's degree and/or four or more years of equivalent work experience in an insurance related industry.
• CA experience is required; AZ experience is a plus.
• License required or ability to obtain within 90 days in mandated states.
• Familiarity with Workers' Compensation terminology and regulations.
• AIC designation or similar is preferred.

Responsibilities

• Investigate assigned claims with minimal supervision and resolve complex cases.
• Determine coverage, compensability, and subrogation potential.
• Set reserves within granted authority and adjust as needed.
• Negotiate settlements within authority and manage case plans.
• Collaborate with PMA nurse for return-to-work strategies.
• Select and manage service vendors to balance expense and outcomes.
• Maintain knowledge of jurisdictional requirements and case law.

Skills

Investigative skills

Claims adjudication

Analytical thinking

Communication

Travel readiness

Education

Bachelor's degree

AIC designation preferred

Tools

MS Office

Word

Excel

PowerPoint

Job description

As a member of our Claims team, utilize your knowledge of Workers Compensation Claims to independently investigate, evaluate and resolve assigned claims of a more complex nature in order to achieve appropriate outcomes. In this position you will administer and resolve highest risk management expectations claims in a timely manner in accordance with legal statues, policy provisions, and company guidelines.

Responsibilities

• Promptly investigates all assigned claims with minimal supervision, including those of a more complex nature
• Determines coverage, compensability, potential for subrogation recovery, and second injury fund (when applicable)
• Alerts Supervisor and Special Investigations Unit to potentially suspect claims
• Ensures timely denial or payment of benefits in accordance with jurisdictional requirements
• Within granted authority, establishes appropriate reserves with documented rationale, maintains and adjusts reserves over the life of the claim to reflect changes in exposure
• Negotiates claims settlements within granted authority
• Establishes and implements appropriate action plans for case resolution including medical and disability management, litigation management, negotiation and disposition
• Works collaboratively with PMA nurse professionals to develop and execute return to work strategies
• Selects and manages service vendors to achieve appropriate balance between allocated expense and loss outcome
• Maintains a working knowledge of jurisdictional requirements and applicable case law for each state serviced
• Demonstrates technical proficiency through timely, consistent execution of best claim practices
• Communicates effectively, verbally and in writing with internal and external parties on a wide variety of claims and account issues
• Provides a high degree of customer service to clients, including face to face interactions during claims reviews, stewardship meetings and similar account-specific sessions
• Authorizes treatment based on the practiced protocols established by statute or the PMA Managed Care department
• Assists PMA clients by suggesting panel provider information in accordance with applicable state statutes.
• Demonstrate commitment to Company’s Code of Business Conduct and Ethics, and apply knowledge of compliance policies and procedures, standards and laws applicable to job responsibilities in the performance of work.

Requirements

• Bachelor's degree and/or four or more years of equivalent work experience required in an insurance related industry required
• CA experience is required; AZ experience is a plus
• Associate in Claims (AIC) Designation or similar professional designation desired
• License required or ability to obtain license within 90 days of employment in mandated states
• Familiarity with medical terminology and/or Workers' Compensation
• Working knowledge of Workers Compensation regulations, preferably jurisdiction-specific
• Strong organizational skills with demonstrated ability to work independently and deal effectively with multiple tasks simultaneously
• Proven critical thinking skills that demonstrate analysis/judgment and sound decision making with focus on attention to details
• Strong verbal, written communication skills and customer service skills gained through previous work experience
• Computer literacy, including working knowledge of MS Office Product Suite, i.e. Word, Excel, PowerPoint
• Ability to travel for business purposes, approximately less than 10%.