Lost Time Claims Specialist, Workers' Compensation

Encova Mutual Insurance Group.; West Virginia; Hybrid; USD 55,000 - 111,000; Full time

Benefits offered by this job

Health, Dental & Vision Insurance

Life and income protection plans

Company incentive bonus program

401(k) with company match

Paid Time Off & Holidays

Job summary

Encova Mutual Insurance Group in the United States seeks a Lost Time Claims Specialist, Workers’ Compensation. You will manage indemnity claims, assess eligibility, and collaborate with medical professionals, legal counsel, and return-to-work specialists to achieve best outcomes.

Candidates should have a bachelor’s degree, at least three years of workers’ compensation experience, and a license. The role offers a competitive salary, bonus eligibility, and a hybrid/remote-friendly structure.

Qualifications

• Bachelor’s degree preferred.
• Three years of workers’ compensation experience required.
• Must pass the adjuster license exam(s) within 90 days of hire.
• Experience with workers’ compensation laws, procedures and state statutes.

Responsibilities

• Manage indemnity and medical benefits to cost-effective conclusions.
• Determine claim eligibility and apply policy guidelines.
• Collaborate with directors, return-to-work specialists, and legal teams.
• Negotiate settlements and coordinate with medical/legal professionals.
• Maintain documentation and adhere to timelines and internal metrics.

Skills

Communication skills

Analytical skills

Multitasking

Independent work

Education

Bachelor’s Degree preferred

Tools

Claims management systems

Microsoft Office

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. For candidates residing in certain states such as Illinois, the salary range is $59,630 to $119,670 annually + bonus + benefits. Pay Type: Salary Candidates who can work remote iin any of our listed payroll approved states.

Lost Time Workers' Compensation claims handling experience in any of the following states Illinois, Wisconsin, Kansas, North Carolina or South Carolina is strongly preferred. The position reports to the Director, Workers' Compensation Claims. We may hire a senior level depending on the candidate's background and experience and the salary range is inclusive of all levels.

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

1. 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.
2. Decides the outcome of the claim using sound judgment by applying established policy, procedures, regulations and guidelines.
3. Gathers facts by conducting interviews with all involved parties and considers all the elements of the claim prior to issuing a decision.
4. Take recorded statements when necessary.
5. Determines eligibility of indemnity and medical benefits once salary information and medical treatment plans have been secured and processed within the designated authority levels.
6. 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.
7. Actively identifies and develops the investigation of and pursuit of subrogation recoveries when possible.
8. 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.
9. Works collaboratively with the injured worker, employer, outside counsel, and health and rehabilitation professionals to manage the claims costs and promote quality medical care.
10. 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.
11. Manages claims litigation, including expenses, by collaborating and providing direction to panel counsel throughout the life of the claim.
12. Analyzes reports from external resources such as physicians, attorneys, and/or vocational rehabilitation experts to evaluate and adjust claim strategies as needed.
13. Evaluates and negotiates claim settlements utilizing human relation skills and technical knowledge to achieve the best possible outcome.
14. Present and summarizes claim details at internal team staffing, participates in discussions, and provides guidance as needed.
15. Consults with assigned claim director if the loss becomes significantly complex or presents significantly increasing financial exposure.
16. Follows established claims best practices related to medical management, litigation, fraud/abuse and recovery.
17. Effectively and independently uses available resources to prioritize, organize, and complete work in a timely manner to meet jurisdictional requirements, timeframes, and internal metrics.
18. Develops presentations for special projects such as internal/external meetings and conferences as needed.
19. Along with the claim director, regional vice president and other claims staff, participates in claim reviews, onboardings, etc. for our policyholders and agents.
20. 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.

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:

• Health, Dental & Vision Insurance
• Company-provided life and income protection plans
• Eligibility to participate in a company incentive bonus program
• 401(k) Retirement Plan - 100% company match up to 7% on annual salary
• Paid Time Off, Paid Holidays, and Floating Holidays
• Flexible Work Arrangements - Hybrid and remote depending on the role

Encova Insurance is an EOE/E-Verify employer.

At Encova Insurance, we firmly believe that our associates drive our company's success by delivering unrivaled service to our customers. With success in mind, we make an ongoing effort to provide an environment that offers challenging, stimulating, and financially rewarding opportunities. Join us to discover a work experience where you can learn and grow to your fullest potential.

We believe that happy, healthy associates are the foundation of great work. Join us and thrive both professionally and personally.

Encova Insurance is an exceptional culture that requires intentional effort from everyone in the company. We believe that achieving results and building trust are interrelated. Through connection, character and competence, we build trusting relationships with associates, agents and policyholders to achieve excellent results.

Through our collaborative team structure we find professional and personal growth. We never stop learning and always seek to improve ourselves. At Encova, we know that inclusion and belonging foster our competitive edge by giving voice to every individual’s unique talent and perspective; and we believe that when a condition of equity exists, all associates can contribute to the fullest extent of their knowledge, skills and ability.