Claims Specialist - Workers Compensation

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

Job summary

Old Republic Commercial Risk is seeking a qualified Claims professional to independently investigate, evaluate, and resolve complex Workers' Compensation claims in a remote position. Responsibilities include determining coverage, negotiating settlements, and coordinating return-to-work plans with PMA nurses.

Requirements include a Bachelor's degree or 4+ years in insurance, California jurisdiction experience, and licensure within 90 days.

Qualifications

• Bachelor's degree or equivalent insurance experience.
• California jurisdiction experience preferred.
• Licensing within 90 days of employment required in mandated states.

Responsibilities

• Investigate complex Workers' Compensation claims with minimal supervision.
• Assess coverage, compensability, and subrogation potential.
• Manage reserves with documented rationale and adjust over time.
• Negotiate settlements within authority and communicate decisions clearly.
• Coordinate return to work strategies with PMA nurses.
• Select and manage service vendors to balance cost and outcomes.
• Provide high levels of customer service during reviews and meetings.

Skills

Strong organizational skills

Strong verbal and written comunicação

Attention to detail

Customer service

MS Office (Word, Excel, PowerPoint)

Education

Bachelor's degree or 4+ years insurance experience

Associate in Claims (AIC) designation preferred

Tools

MS Office Suite

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