Claims Specialist - Workers Compensation

Old Republic Commercial Risk; City of Syracuse (NY); On-site; USD 70,000 - 95,000; Full time

Job summary

Old Republic Commercial Risk is seeking a Claims professional to independently investigate, evaluate, and resolve complex workers' compensation claims. You will determine coverage, reserves, and potential subrogation while coordinating with PMA nurse professionals for return-to-work strategies.

Required are a Bachelor's degree (or 4+ years in insurance), CA experience, and the ability to obtain licensure within 90 days. Strong organizational, analytical and communication skills are essential.

Qualifications

• Bachelor's degree or four+ years of related work experience.
• CA experience required; AZ experience is a plus.
• AIC designation or similar professional designation desired
• License required or ability to obtain license within 90 days in mandated states
• Familiarity with medical terminology and Workers' Compensation
• Strong organizational and communication skills

Responsibilities

• Investigates assigned complex workers' compensation claims promptly and with minimal supervision.
• Determines coverage, compensability, potential subrogation and second injury fund when applicable.
• Alerts Supervisor and SIU to suspect claims and ensures timely denial or payment of benefits.
• Establishes reserves with rationale and adjusts them as exposure changes.
• Negotiates settlements within granted authority and plans case resolution including medical and disability management.
• Collaborates with PMA nurse professionals on return-to-work strategies.
• Manages service vendors to balance expense and loss outcomes.
• Maintains knowledge of jurisdictional requirements and applicable case law.
• Communicates with internal/external parties effectively, in writing and verbally.
• Provides high level of customer service during reviews and stewardship meetings.
• Authorizes treatment per statute and PMA Managed Care protocols; supports PMA clients with panel provider information.
• Demonstrates compliance with Company policies and ethics.

Skills

Analytical thinking

Communication

Customer service

Time management

Independent work

Attention to detail

Education

Bachelor's degree

AIC designation

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%.