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Description
Claims Specialist
Position Summary
The Claims Specialist is responsible for overseeing a portfolio of workers’ compensation and liability claims, ensuring timely reporting, proper investigation, accurate documentation, and effective claim resolution. This role works closely with internal departments, insurers, brokers, medical providers, attorneys, and external business partners to reduce claim costs, manage risk, and support return-to-work and loss control initiatives.
Essential Functions
- Oversee a portfolio of workers’ compensation and liability claims.
- Review new claims to ensure timely reporting, appropriate claim assignment, and accurate investigation.
- Review claim investigations, compensability determinations, liability assessments, reserve recommendations, and settlement strategies.
- Analyze claim trends, identify high-exposure cases, and recommend proactive strategies to reduce organizational risk and claim costs.
- Collaborate with Human Resources, Risk Management, Safety, Operations, and department leadership to facilitate timely claim reporting and resolution.
- Coordinate return-to-work and modified duty programs to promote employee recovery and reduce indemnity costs.
- Review medical treatment plans, utilization, and disability status while working with nurse case managers and medical providers.
- Participate in claim review meetings with insurers and brokers.
- Prepare and distribute periodic claim reviews for self-handled claims to internal stakeholders.
- Authorize claim payments, reserve changes, settlements, and litigation strategies within delegated authority.
- Ensure compliance with state workers’ compensation statutes and internal policies.
- Identify fraud, subrogation, and recovery opportunities and coordinate appropriate actions.
- Maintain complete and accurate claim documentation and internal reporting records.
- Prepare periodic reports summarizing claim activity, loss trends, and program performance.
- Support organizational initiatives related to workplace safety, injury prevention, and loss control.
- Maintain positive working relationships with employees, supervisors, healthcare providers, attorneys, and external business partners.
Required Education, Experience, and Skills
- High school diploma or equivalent required; associate degree or higher preferred.
- Minimum of 5–7 years of claims handling experience with a large retail broker or national insurer.
- Current Claims Adjuster License preferred.
- Progressively increasing experience handling complex auto liability and workers’ compensation claims.
- Experience with Microsoft Office applications required.
- Experience with technical tools such as HRIS and payroll systems is helpful.
- Experience working closely with confidential and proprietary information while maintaining integrity and discretion.
- Strong professional team player with effective collaboration, organizational, and relationship-building skills.
- Demonstrated high level of integrity, dependability, and professionalism.
- Ability to manage workflow and meet deadlines in a fast-paced environment with multiple and sometimes changing priorities.
- Excellent written communication skills, including high-quality documentation and report preparation.
- Strong listening, interpersonal, verbal, and telephone communication skills.
- Strong independent problem-solving skills, attention to detail, customer service skills, and time management abilities.
- Process-oriented mindset preferred.