Senior Workers' Comp Claims Specialist - Complex Claims

Old Republic Commercial Risk; Center Square (PA); On-site; USD 65,000 - 90,000; Full time

Job summary

Old Republic Commercial Risk seeks an experienced claims professional to independently investigate, evaluate, and resolve high-complexity Workers' Compensation claims. You will administer and resolve claims in compliance with statutes, policy provisions, and company guidelines from a dedicated claims team.

Responsibilities include determining coverage, managing reserves, negotiating settlements, and coordinating with PMA nurses on return-to-work strategies while maintaining strong client service

Qualifications

• Bachelor's degree or four+ years of equivalent work experience in an insurance related industry.
• At least 3-5 years' experience handling lost time workers' compensation claims; NJ and PA jurisdiction experience required.
• Active license required or ability to obtain license within 90 days of employment in mandated states.
• Associate in Claims (AIC) designation desirable.
• Familiarity with medical terminology and/or Workers' Compensation.

Responsibilities

• Promptly investigate all assigned claims with minimal supervision, including those of a more complex nature
• Determine coverage, compensability, potential for subrogation recovery, and second injury fund (when applicable)
• Alert Supervisor and Special Investigations Unit to potentially suspect claims
• Ensure timely denial or payment of benefits in accordance with jurisdictional requirements
• Establish appropriate reserves with documented rationale, maintain and adjust reserves over the life of the claim to reflect changes in exposure
• Negotiate claims settlements with client approval
• Establish and implement appropriate action plans for case resolution including medical and disability management, litigation management, negotiation and disposition
• Work collaboratively with PMA nurse professionals to develop and execute return to work strategies
• Select and manage service vendors to achieve appropriate balance between allocated expense and loss outcome
• Maintain a working knowledge of jurisdictional requirements and applicable case law for each state serviced
• Demonstrate technical proficiency through timely, consistent execution of best claim practices
• Communicate effectively, verbally and in writing with internal and external parties on a wide variety of claims and account issues
• Provide a high degree of customer service to clients, including face to face interactions during claims reviews, stewardship meetings and similar account-specific sessions
• Authorize treatment based on the practiced protocols established by statute or the PMA Managed Care department
• Assist 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.

Skills

Organizational skills

Analytical thinking

Verbal and written communication

Customer service

Attention to detail

Education

Bachelor's degree / equivalent experience

Tools

MS Office

Job description

Old Republic Commercial Risk seeks an experienced claims professional to independently investigate, evaluate, and resolve high-complexity Workers' Compensation claims. You will administer and resolve claims in compliance with statutes, policy provisions, and company guidelines from a dedicated claims team.

Responsibilities include determining coverage, managing reserves, negotiating settlements, and coordinating with PMA nurses on return-to-work strategies while maintaining strong client service