Claims Specialist

GENERAL DESCRIPTION
The Claims Specialist independently adjudicates multi-state worker’s compensation indemnity, Employers Liability, and subrogation claim files that require a higher degree of complexity.
ESSENTIAL FUNCTIONS
1. Responsible for reviewing claims following internal transfer to ensure proper management in accordance with company’s Best Practices.
2. Responsible for customer relations management, consistently establishing and maintaining high levels of trust and confidence with clients, through constant contacts, prompt response and resolving client’s questions and claim issues.
3. Aggressively manages all aspects of the workers’ compensation claims management process inclusive of litigation, and providing direction to defense counsel.
4. Responsible for setting of reserves to Ultimate Probable Cost (UPC). Sets reserves for anticipated exposure subject to authority limits.
5. Addresses timely benefit delivery and acknowledges any penalties due in accordance with State regulations.
6. Coordinates return to work (RTW) in accordance with the medical disability plan for the injured worker.
7. Manages and directs defense involving coverage disputes.
8. Maintain active diary in 30 day intervals.
9. Negotiates settlements directly with the injured worker or opposing counsel.
10. Considers Medicare’s interests related to conditional payments, injured workers eligibility and settlements.
11. Recognizes and manages 3rd party liability and subrogation through recovery.
12. Documents files appropriately in claims system.
13. Reviews medical and expense bills for causal relationship, and bill charges over $1500.00.
14. Consults with Claim Supervisor/Claims Manager/Executive claims on those files where assistance and consultation is needed.
15. Completion of Claims Status reports.
16. Coordinate claim review meetings with both internal and external parties.
17. Attend hearings or depositions, when required.
18. Assist and mentor claims personnel when needed.
19. All other duties as assigned.
COMPETENCIES/QUALIFICATIONS
• Professional telephone demeanor, good verbal and written communication skills, good listening skills, along with strong organizational skills.
• Thorough knowledge of workers’ compensation and EL claims procedures and policies.
• Possess a strong understanding of human nature and motivation principles.
• Readily control/handle problem issues in times of stress and in a climate of conflict and/or adversity.
• Computer literacy including strong familiarity with Microsoft Office Suite. Ability to type 45 WPM.
• Basic understanding of business technology.
• Responsiveness to changing business needs.
• Ability to work well under pressure and multi-task in a fast paced environment while continually paying attention to detail.
• Ability to adhere to the code of ethical conduct and engage in fair claims settlement practices.
• Ability to take direction and make decisions.
• Ability to learn new procedures quickly and adapt to a changing environment.
• Ability to work in a team environment.
• Ability to work with limited supervision.
EDUCATION/EXPERIENCE REQUIREMENTS
• Minimum Education: Bachelor’s degree.
• 5+ years of compensation management experience with an emphasis on litigation.
• Prefer relevant state licensing or ability to gain licensing is required in a variety of jurisdictions.
SUPERVISORY RESPONSIBILITY
The Claims Specialist has no formal supervisory responsibility but often assists, mentors, and trains less experienced staff.