Sr Claims Specialist

Old Republic Commercial Risk; Wilmington (NC); On-site; USD 60,000 - 90,000; Full time

Job summary

Old Republic Commercial Risk is seeking an experienced claims professional to investigate, evaluate, and resolve high-complexity workers' compensation claims. You will handle coverage, compensability, and subrogation while ensuring timely decisions and reserves are set with documented rationale.

In this role you will negotiate settlements, collaborate with PMA nurses on return-to-work strategies, and manage vendor relationships to balance costs with outcomes.

Qualifications

• Bachelor's degree or four+ years in insurance industry experience.
• Experience handling workers' compensation claims, including NC/SC/MS jurisdictions.
• Active license or ability to obtain within 90 days in required states.
• Familiarity with medical terminology and workers' compensation processes.

Responsibilities

• Investigate and resolve high complexity claims with minimal supervision.
• Determine coverage, compensability, and potential subrogation.
• Manage reserves and negotiate settlements with client approval.
• Collaborate with PMA nurses on return-to-work strategies and case plans.
• Liaise with vendors, provide communication to internal/external parties.
• Maintain knowledge of jurisdictional requirements and case law.

Skills

Strong communication

Organizational skills

Critical thinking

Customer service

Attention to detail

Travel readiness

Education

Bachelor's degree or equivalent experience

Tools

MS Office

MS Word

MS Excel

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%.