Claims Specialist - Workers Compensation

Old Republic Commercial Risk; Fresno (CA); On-site; USD 70,000 - 85,000; Full time

Job summary

Old Republic Commercial Risk is seeking a qualified Claims professional in California to independently investigate and resolve complex workers’ compensation claims. You will determine coverage, reserves, and settlements, while coordinating with PMA nurses for return‑to‑work strategies and working with service vendors to balance expenses and outcomes.

The role requires a bachelor's degree or equivalent insurance experience, California jurisdiction knowledge, and the ability to obtain licensure

Qualifications

• Bachelor's degree and/or four or more years of equivalent work experience in insurance required.
• California jurisdiction experience preferred and licensed or able to obtain license within 90 days.
• Familiarity with medical terminology and Workers' Compensation regulations.

Responsibilities

• Investigates assigned claims with minimal supervision, including complex cases.
• Determines coverage, compensability, subrogation potential, and second injury fund applicability.
• Alerts supervisor and SIU to potentially suspect claims.
• Ensures timely denial or payment of benefits per jurisdictional requirements.
• Establishes and adjusts reserves with documented rationale throughout the claim life.
• Negotiates settlements within granted authority and collaborates with vendors and PMA team.

Skills

Communication skills

Customer service

Organizational skills

Analytical thinking

Attention to detail

Education

Bachelor's degree or 4+ years insurance experience

Associate in Claims (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
• 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.
• Target salary range - $70,000 - $85,000
• 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.
• California jurisdiction experience
• 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%.
• Remote position