Sr Claims Specialist

Old Republic Commercial Risk; Raleigh (NC); On-site; < USD 1; Full time

Job summary

Old Republic Commercial Risk in Raleigh, NC seeks a seasoned claims professional to independently investigate, evaluate, and resolve high-risk workers' compensation claims. You will administer and resolve complex claims in line with statutes, policy provisions, and company guidelines.

Responsibilities include determining coverage and compensability, managing reserves, negotiating settlements, and coordinating with PMA nurses on return-to-work plans. Travel is required occasionally.

Qualifications

• Bachelor's degree or equivalent experience in insurance is required.
• 3-5 years' experience handling lost time workers' compensation claims is required; NC, SC and MS jurisdiction experience is required.
• Active license in mandated states or ability to obtain within 90 days.

Responsibilities

• Investigate and resolve assigned workers' compensation claims with minimal supervision.
• Determine coverage, compensability, subrogation potential, and second injury fund applicability.
• Maintain appropriate reserves and adjust over the life of the claim.
• Negotiate settlements with client approval and communicate effectively with stakeholders.
• Collaborate with PMA nurse professionals on return-to-work strategies and case management.
• Travel for business purposes as needed (less than 10%).

Skills

Organizational skills

Critical thinking

Verbal communication

Written communication

Customer service

Education

Bachelor's degree or equivalent work experience in insurance

Tools

MS Office

Job description

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 statutes, 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 NC, SC and MS 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%.