Sr. Claims Specialist

Old Republic Commercial Risk; Charleston (WV); On-site; USD 65,000 - 90,000; Full time

Job summary

Old Republic Commercial Risk seeks a claims professional to investigate, evaluate, and resolve high-complexity workers' compensation claims. You will administer and resolve the highest risk management claims in a timely manner in line with statutes, policy provisions, and company guidelines.

You will determine coverage and eligibility, manage reserves, negotiate settlements, and coordinate return-to-work strategies with PMA nurses.

Qualifications

• Bachelor's degree or four+ years of equivalent work experience in an insurance related industry.
• 3-5 years' experience handling lost time workers compensation claims; MD/DC/WV/PA jurisdiction experience.
• Active license required or ability to obtain license within 90 days in mandated states.

Responsibilities

• Investigate assigned claims with minimal supervision, including complex cases.
• Determine coverage, compensability, and subrogation potential.
• Maintain reserves with documented rationale and adjust over the life of the claim.
• Negotiate settlements with client approval and appropriate documentation.
• Collaborate with PMA nurses to develop return-to-work strategies.
• Select and manage service vendors to balance expense and loss outcome.
• Communicate effectively with internal and external parties.

Skills

Verbal communication

Written communication

Customer service

Organizational skills

Attention to detail

Analytical thinking

Education

Bachelor's degree

AIC designation

Tools

MS Office (Word, Excel, PowerPoint)

Job description

As a member of our claims team, utilize your knowledge of Workers Compensation 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 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.

Requirements

• Bachelor's degree, or four or more years of equivalent work experience required in an insurance related industry required
• At least 3-5 years' experience handling lost time workers compensation claims required; past experience with MD, DC, WV and PA jurisdiction is required
• Associate in Claims (AIC) Designation or similar professional designation desired.
• Active license required or ability to obtain license within 90 days of employment in mandated states.
• Familiarity with medical terminology and/or Workers' Compensation
• 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
• 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%.