Lost Time Claims Specialist - Workers' Compensation

About the role

The Lost Time Claims Specialist, Workers’ Compensation primarily manages indemnity claims. The role involves investigating, evaluating, and determining compensability for work-related injury and disease claims following established guidelines to determine benefit eligibility. The position also serves as a resource to Medical Only Claims Specialists and Claims Specialist Trainees.

Responsibilities

• Evaluates and establishes an action plan to manage medical and indemnity benefits associated with injury and occupational disease claims to their most cost-effective conclusion.
• Decides the outcome of the claim using sound judgment by applying established policy, procedures, regulations and guidelines.
• Gathers facts by conducting interviews with all involved parties and considers all the elements of the claim prior to issuing a decision.
• Determines eligibility of indemnity and medical benefits once salary information and medical treatment plans have been secured and processed within the designated authority levels.
• Utilize proactive reserving behaviors to ensure adequate case reserves which reflect the probable ultimate outcome based on the current known circumstances throughout the life of the claim.
• Actively identifies and develops the investigation of and pursuit of subrogation recoveries when possible.
• Consults with assigned claim director, return to work specialists, nurse case managers, internal/external medical, and legal on current and/or recommended treatment, litigation or rehabilitation plans to ensure claims outcomes are achievable and appropriate.
• Works collaboratively with the injured worker, employer, outside counsel, and health and rehabilitation professionals to manage the claims costs and promote quality medical care.
• Works collaboratively with the injured worker, employer, assigned return to work specialist, and medical providers to facilitate the injured worker’s safe and timely return to work.
• Manages claims litigation, including expenses, by collaborating and providing direction to panel counsel throughout the life of the claim.
• Analyzes reports from external resources such as physicians, attorneys, and/or vocational rehabilitation experts to evaluate and adjust claim strategies as needed.
• Evaluates and negotiates claim settlements utilizing human relation skills and technical knowledge to achieve the best possible outcome.
• Presents and summarizes claim details at internal team staffing, participates in discussions, and provides guidance as needed.
• Consults with assigned claim director if the loss becomes significantly complex or presents significantly increasing financial exposure.
• Follows established claims best practices related to medical management, litigation, fraud/abuse and recovery.
• Effectively and independently uses available resources to prioritize, organize, and complete work in a timely manner to meet jurisdictional requirements, timeframes, and internal metrics.
• Develops presentations for special projects such as internal/external meetings and conferences as needed.
• Along with the claim director, regional vice president and other claims staff, participates in claim reviews, onboardings, etc. for our policyholders and agents.
• Proactively collaborate with our policyholders to ensure alignment of objectives and foster continuous improvement.

Qualifications

• Bachelor’s Degree from an accredited college or university is preferred.
• Three years of experience in the field of workers’ compensation insurance required.
• Ability to manage claims through the litigation process.
• Internal candidates must demonstrate knowledge of Encova Best Practices guidelines and meet quality standards.
• One valid workers’ compensation adjuster license is strongly preferred.
• Must be eligible to obtain additional licenses as required.
• Must pass the claims adjuster license exam(s) as assigned within 90 days of being hired.
• Preference may be shown to candidates with multiple state claims management experience.
• Experience in workers’ compensation claims practices and laws, court procedures, precedents and state statutes.
• Ability to use logic and sound reasoning to identify alternative solutions for problem-solving.
• Strong written and verbal communication skills.
• Strong analytical skills.
• Ability to multitask and manage time effectively and productively.
• Work effectively independently as well as in a team environment.
• Develop and maintain strong, effective internal and external relationships.
• Work effectively in a paperless environment.
• Skilled in the use of laptops, claims management systems, and other typical business-related programs such as Microsoft Office suite.

Skills

• Knowledge of workers’ compensation laws and regulations.
• Ability to manage and resolve complex claims.
• Excellent communication and interpersonal skills.
• Strong analytical and problem-solving abilities.
• Ability to work independently and as part of a team.
• Proficiency in claims management software and systems.

Benefits

Encova Insurance offers a comprehensive benefits package designed to support the well-being and growth of our associates. Available benefits (subject to any policy or plan changes) include, but are not limited to:

• Health, Dental & Vision Insurance
• Company-provided life and income protection plans
• Eligibility to participate in a company incentive bonus program
• 401(k) Retirement Plan - 100% company match up to 7% on annual salary
• Paid Time Off, Paid Holidays, and Floating Holidays
• Flexible Work Arrangements - Hybrid and remote depending on the role