Workers' Compensation Claims Specialist

The Workers' Compensation Claims Specialist is responsible for managing and processing claims related to workplace injuries or illnesses for a nationwide Professional Employer Organization (PEO). The Claims Specialist works with employers, employees, medical providers, and insurance carriers' Adjusters to ensure that the claims are handled in a timely & appropriate manner and effectively communicates the benefits of return-to-work programs to employers for lost time claims. The claims Specialist performs investigations, analysis of complex or disputed claims and works with outside counsel on settlements for litigated claims.

Additional duties include coordination of medical treatment and referrals, completion of claims documentation including wage statements, generation of medical panels, issuing certificates of insurance, preparation for claims reviews with detailed status updates and strategic action plans.

Works closely with Senior Management to ensure claims are handled in an appropriate and consistent manner with quality claims management in accordance with state WC claims laws, fair, and ethical practices. The Claims Specialist is responsible for the prompt and efficient examination, investigation and settlement or declination of claims through effective research, negotiation and interaction with Adjusters, insureds, brokers and outside counsel, ensuring that company resources are utilized in a cost-effective manner in the process.

The Role. . .

• Promptly review and evaluate workers' compensation incident reports from the intake vendor to provide carrier Adjusters with pertinent information to determine claims eligibility, coverage, and benefits.

• Initiate and provide excellent communication with claimants, employers, medical providers, and insurance carriers to obtain relevant information, documentation, investigation, and analysis to make a compensability determination, recommend a course of action, authorize payment, or denials accordingly.

• Consistently question and probe all aspects of claims professionally and proactively with a customer-centric approach to achieve full understanding of facts and investigate potential fraud indicators in collaboration with Adjusters, Senior Management, and brokers.

• Coordinate medical treatment and referrals for claimants and monitor their recovery and return to work status.

• Accurate completion of 13-week wage statements for lost time claims to administer the delivery of accurate indemnity payments.

• Effectively communicate the benefits of return-to-work programs and provide resources to employers with a high-level of customer service that promotes injured worker advocacy-based principles to maximize return-to work motivation and improve outcomes for all parties.

• Recognize and investigate subrogation opportunities for recovery of third-party funds.

• Build rapport with policyholders to educate them on claims reporting procedures, policies, and claim practices to include accountability while managing service expectations.

• Investigate and resolve any issues or disputes that arise during the claim process.

• Negotiate and settle claims within the authority limits and policy guidelines.

• Prepare and maintain accurate and complete records and reports of claims activities.

• Prepare and participate in internal claims reviews and stewardship meetings with large policyholders while applying knowledge of compliance policies and applicable laws.

• Works collaboratively with Senior Management to manage service & intake vendors to achieve appropriate balance between allocated expense and loss outcomes.

• Process post-accident drug tests for payment and trigger activity in case of positive drug test.

• Generate Medical Panels for employer worksites in accordance with state statutes.

• Issue Certificates of Insurance for Workers' Compensation in a timely manner with complete and correct information.

• Occasionally prepare and coordinate special documents such as OSHA logs.

• Comply with all federal, state, and local laws and regulations related to workers' compensation.

• Stay updated on the latest trends and developments in the workers' compensation field.

• Preparation of renewal documents, notifications, and labels.

• Recommend process improvements where applicable to improve department efficiency, work product, and service commitment to stakeholders.

• Additional responsibilities include completion of tasks/projects assigned by management.

The Ideal Candidate. . .

• Bachelor's degree and/or five or more years of experience in an insurance related industry.

• Must have a 6-20 Certified Adjuster License.

• Minimum of five years of experience in workers' compensation claims handling.

• Maintains a working knowledge of jurisdictional requirements and applicable case law for each state serviced.

• Strong knowledge of insurance/medical terminology related to workers' compensation.

• Proven critical thinking skills that demonstrate analysis/judgement and sound decision making with focus on attention to details.

• Excellent communication (verbal and written), interpersonal, and customer service skills gained through previous work experience.

• Basic knowledge of NCCI workers' compensation classifications

• Strong organizational skills with demonstrated ability to work independently and deal effectively with multiple tasks simultaneously. Balances teamwork and individual responsibilities.

• Proficiency in Microsoft Office and claims management software.