Claims Specialist - Workers Compensation

Old Republic Commercial Risk; City of Utica (NY); On-site; USD 75,000 - 105,000; Full time

Job summary

Old Republic Commercial Risk in Utica, NY seeks an experienced Claims professional to independently handle complex Workers’ Compensation claims. You will investigate, evaluate, and resolve assigned claims, determine coverage and reserves, and coordinate with medical providers to achieve timely, fair outcomes.

You will negotiate settlements within authority and manage litigations, while ensuring compliance with state regulations and company standards. Travel is minimal.

Qualifications

• Bachelor's degree or 4+ years in insurance required
• CA experience required; AZ experience a plus
• License required or obtainable within 90 days
• Familiarity with Workers' Compensation regulations expected
• Strong organizational skills and ability to multitask
• Proficient in MS Office (Word, Excel, PowerPoint)

Responsibilities

• Investigate assigned claims with minimal supervision, including complex cases
• Determine coverage, compensability, subrogation potential, and second injury fund when applicable
• Alert Supervisor and SIU to potentially suspect claims
• Ensure timely denial or payment of benefits per jurisdictional requirements
• Establish reserves with rationale and adjust over the life of the claim
• Negotiate settlements within granted authority
• Develop action plans for case resolution including medical/disability management, litigation, and negotiation
• Collaborate with PMA nurses to execute return-to-work strategies
• Select and manage service vendors to balance costs and loss outcomes
• Maintain knowledge of jurisdictional requirements and case law for states served
• Demonstrate proficiency through timely execution of best claim practices
• Communicate effectively with internal and external parties
• Provide high level customer service during reviews and meetings
• Authorize treatment per PMA protocols
• Suggest panel providers per state statutes
• Adhere to Code of Business Conduct and ethics

Skills

Communication

Organization

Critical thinking

Attention to detail

Independent worker

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%.