Lost Time Claims Specialist - Workers' Compensation

Encova Insurance

Charleston (WV)

Hybrid

USD 55,132 - 110,642

Full time

14 days+

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Benefits offered by this job

Health, Dental & Vision Insurance

Life and income protection plans

Bonus program eligibility

401(k) with company match

Paid time off and holidays

Hybrid and remote options

Job summary

Encova Insurance is seeking a Lost Time Claims Specialist to manage Workers' Compensation indemnity claims across multiple jurisdictions, focusing on lost time and medical-only claims. The role emphasizes investigation, evaluation, and determination of compensability while collaborating with medical and legal teams to ensure cost-effective outcomes.

Ideal candidates will have WC claims experience, strong communication, and the ability to navigate complex state regulations.

Qualifications

Bachelor's degree from an accredited college or university preferred.
Three years of workers' compensation insurance experience required.
Ability to manage claims through the litigation process.
Must pass the claims adjuster license exam within 90 days of hire.
Strong written and verbal communication skills.
Ability to multitask and manage time effectively.

Responsibilities

Evaluates and plans to manage medical and indemnity benefits to cost-effective conclusions.
Decides claim outcomes using policy, procedures, and guidelines.
Gathers facts via interviews with involved parties and documents evidence.
Determines eligibility of indemnity and medical benefits.
Collaborates with claim directors, return-to-work specialists, and medical providers to control costs.
Manages litigation with panel counsel throughout the life of the claim.
Develops subrogation opportunities when possible.
Presents claim details at internal team meetings and provides guidance as needed.
Supports return-to-work processes with injured workers and employers.
Ensures compliance with jurisdictional requirements and internal policies.

Skills

WC claims experience

Strong communication

Analytical skills

Time management

Litigation knowledge

Education

Bachelor's degree

Job description

The salary range for this job posting is $55,132.00 - $110,642.00 annually + bonus + benefits. Pay Type: Salary

The above represents the full salary range for this job requisition. Ultimately, in determining your pay and job title, we'll consider your location, education, experience, and other job-related factors, and will fall within the stated range. Your recruiter can share more information about the specific salary range during the hiring process.

We would prefer candidates who reside in Pennsylvania or West Virginia however, will consider those who reside in any of our listed payroll approved states with the related experience.

This role will manage Workers' Compensation Lost Time and Medical Only claims within multiple jurisdictions. However, ideal candidates will have experience managing Workers' Compensation lost time claims in Pennsylvania and/or West Virginia and Maryland.

We may hire a senior level depending on the candidate's background and experience and the salary range is inclusive of all levels. The position reports to a Director, Workers' Compensation Claims.

Unique residence requirements are listed in each job posting, please review closely for details.

Encova is only able to employ associates who reside and work within specific U.S. states. Our current policies are based on the laws in states in which we are registered for payroll. Our current footprint includes: Connecticut, Delaware, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nebraska, New Hampshire, New Jersey, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, West Virginia, Wisconsin.

JOB OBJECTIVE

The Lost Time Claims Specialist, Workers' Compensation primarily manages indemnity claims. The Lost Time Claims Specialist is responsible for the investigation, evaluation, and determination of compensability for work-related injury and disease claims following established guidelines to determine benefit eligibility. The Lost Time Claims Specialist also serves as a resource to Medical Only Claims Specialists and Claims Specialist Trainees. The position's objective is to provide superior service in a cost-effective manner to achieve best possible outcomes as well as proactively collaborate across the enterprise to ensure alignment of objectives and foster continuous improvement.

ESSENTIAL FUNCTIONS

Evaluates and establishes an action plan to manage medical and indemnity benefits associated with injury and occupational disease claims to their most cost- effective conclusion.

Decides the outcome of the claim using sound judgment by applying established policy, procedures, regulations and guidelines.

Gathers facts by conducting interviews with all involved parties and considers all the elements of the claim prior to issuing a decision.

Take recorded statements when necessary.

Determines eligibility of indemnity and medical benefits once salary information and medical treatment plans have been secured and processed within the designated authority levels.

Utilize proactive reserving behaviors to ensure adequate case reserves which reflect the probable ultimate outcome based on the current known circumstances throughout the life of the claim.

Actively identifies and develops the investigation of and pursuit of subrogation recoveries when possible.

Consults with assigned claim director, return to work specialists, nurse case managers, internal/external medical, and legal on current and/or recommended treatment, litigation or rehabilitation plans to ensure claims outcomes are achievable and appropriate.

Works collaboratively with the injured worker, employer, outside counsel, and health and rehabilitation professionals to manage the claims costs and promote quality medical care.

Works collaboratively with the injured worker, employer, assigned return to work specialist, and medical providers to facilitate the injured worker's safe and timely return to work.

Manages claims litigation, including expenses, by collaborating and providing direction to panel counsel throughout the life of the claim.

Analyzes reports from external resources such as physicians, attorneys, and/or vocational rehabilitation experts to evaluate and adjust claim strategies as needed.

Evaluates and negotiates claim settlements utilizing human relation skills and technical knowledge to achieve the best possible outcome.

Present and summarizes claim details at internal team staffing, participates in discussions, and provides guidance as needed.

Consults with assigned claim director if the loss becomes significantly complex or presents significantly increasing financial exposure.

Follows established claims best practices related to medical management, litigation, fraud/abuse and recovery.

Effectively and independently uses available resources to prioritize, organize, and complete work in a timely manner to meet jurisdictional requirements, timeframes, and internal metrics.

Develops presentations for special projects such as internal/external meetings and conferences as needed.

Along with the claim director, regional vice president and other claims staff, participates in claim reviews, onboardings, etc. for our policyholders and agents.

Proactively collaborate with our policyholders to ensure alignment of objectives and foster continuous improvement.

OTHER FUNCTIONS

Nonessential function: other duties as assigned.

KNOWLEDGE, SKILLS AND ABILITIES

Bachelor's Degree from an accredited college or university is preferred.

Three years of experience in the field of workers' compensation insurance required.

Ability to manage claims through the litigation process.

Internal candidates must demonstrate knowledge of Encova Best Practices guidelines and meet quality standards.

One valid workers' compensation adjuster license is strongly preferred. Must be eligible to obtain additional licenses as required.

Must pass the claims adjuster license exam(s) as assigned within 90 days of being hired.

Preference may be shown to candidates with multiple state claims management experience.

Experience in workers' compensation claims practices and laws, court procedures, precedents and state statutes.

Ability to use logic and sound reasoning to identify alternative solutions for problem-solving.

Strong written and verbal communication skills.

Strong analytical skills.

Ability to multitasks and manage time effectively and productively.

Work effectively independently as well as in a team environment.

Develop and maintain strong, effective internal and external relationships.

Work effectively in a paperless environment.

Skilled in the use of laptops, claims management systems, and other typical business-related programs such as Microsoft Office suite.

This position has been evaluated in accordance with the Americans with Disabilities Act. Encova Insurance makes every effort to reasonably accommodate disabilities to permit performance of the essential functions and candidates who need such accommodation are encouraged to seek it. This description reflects the nature and level of work performed by associates in this position. It is not an all-inclusive inventory of duties, responsibilities and qualifications required. It provides an accurate overview of the work and skills needed to perform this position. Because job content may change from time to time, Encova Insurance reserves the right to add and/or delete functions from this job as it deems necessary for business reasons.

What you can expect from us

In addition to a competitive compensation package, we offer a comprehensive benefits package designed to support the well-being and growth of our associates. Available benefits (subject to any policy or plan changes) include, but are not limited to: