Workers' Compensation Claim Specialist

Job Summary

The Workers’ Compensation Claim Specialist is responsible for managing a caseload consisting primarily of litigated and some complex claims, ensuring timely and accurate payment of benefits while delivering high-quality service to our clients. This role involves conducting investigations, determining compensability, managing medical treatment through maximum medical improvement (MMI), and maintaining appropriate reserves throughout the life of the claim. The Claim Specialist works closely with clients, defense counsel, and medical providers to evaluate claims for settlement, negotiate resolutions, and bring cases through settlement and closure.

Responsibilities

• Investigate, evaluate and adjust claims in accordance with established claim handling standards and laws.
• Establish reserves and/or provide reserve recommendations within established reserve authority levels.
• Review, approve or provide oversight of medical, legal, damage estimates and miscellaneous invoices to determine if reasonable and related to designated claims.
• Negotiate any disputed bills or invoices for resolution.
• Authorize and make payments of claims in accordance with claim procedures utilizing a claim payment program in accordance with industry standards and within established payment authority.
• Negotiate settlements in accordance within Corporate Claim Standards, client specific handling instructions and state laws, when appropriate.
• Absorb and maintain personal diary on claim system.
• Assess and monitor subrogation claims for resolution.
• Compute disability rates in accordance with state laws.
• Effective and timely coordination of communication with clients, claimants and other appropriate parties throughout the claim adjustment process.
• Provide notices of qualifying claims to excess/reinsurance carriers.
• Compliance with Corporate Claim Handling Standards and special client handling instructions as established.

Qualifications

• 10+ years of Workers’ Compensation claims handling experience, including full claim investigation, evaluation, and resolution.
• Proof of current CEU credits.
• Responsiveness to internal and external client needs.
• Strong analytical and negotiation abilities.
• Knowledge of all lower-level claim position responsibilities.
• Experience handling litigated and complex claims.

Nice to Have

• Bilingual (Spanish) proficiency — highly valued for communicating with claimants, employers, or vendors, but not required.
• SIP is preferred.
• Bachelor's degree is preferred but not required.
• Professional designations such as AIC, ARM, or CPCU are preferred but not required.