Workers Compensation Claims Specialist, Sr

Responsibilities

• Ensure quality management of claims in accordance with claims best practices and company guidelines, and timely, accurate documentation of claim activity
• Provide a high level of customer service that promotes injured worker advocacy-based principles to improve outcomes for all parties
• Determine compensability and coverage issues by gathering medical and factual evidence
• Evaluate the claim for potential fraud indicators and escalate the claim to SIU, as appropriate
• Recognize and investigate subrogation opportunity and refer to NJM subrogation staff for recovery of third-party funds
• Initiate and provide excellent communication with all stakeholders (injured workers, medical providers, attorneys, policyholders, agents, etc.) professionally and proactively with a customer-centric approach
• Apply critical thinking skills to evaluate and mitigate exposures, and establish and implement a proactive strategic plan of action
• Assign and refer claim petitions to Counsel, and work to resolve the claim within given authority
• Build rapport with policyholders and agents, conduct on-site investigations when necessary, and educate policyholders and agents on NJM procedures, policies, and claim practices
• Prepare and attend Claim Reviews at policyholder or agent locations in Western and/or Central PA or virtually for further locations
• Serve as a liaison between policyholders/agents and various departments in NJM
• Represent WC Claim in on-site capabilities meetings to onboard new policyholders in Western and/or Central PA
• Participate in training programs to keep current on relevant issues/topics
• Recommend process improvement where applicable to best improve the department efficiency, work product, and service commitment to interested parties

Requirements

• 5+ years’ experience as a Workers' Comp Claim Representative, or comparable knowledge and experience with various aspects of claims handling and/or process including advanced knowledge of medical terminology and WC regulations for PA, MD and/or DE claims
• Knowledge of and/or experience working with liens and Medicare Set-Asides to secure full and final settlements
• Customer service oriented with strong written and oral communication skills
• Strong interpersonal skills with ability to work both in a team and independently
• Demonstrated organizational skills, and use of sound decision-making capabilities
• Working knowledge utilizing an automated claim processing system and Microsoft Office tools including Word and Outlook
• Licensed in DE and/or CT to adjust WC claims or have the ability to obtain these licenses within 90 days
• Ability to travel for business purposes, approximately 2 – 3 days a week meeting with policyholders and/or agents

Qualifications And Experience

• Associate or bachelor’s degree
• AIC/CPCU or other applicable insurance designations
• Experience using Guidewire Claim Center, OnBase and additional Microsoft Office tools including Teams, Excel and PowerPoint
• Knowledge and experience in claims handling for other commercial line products in various states including PA, MD and/or DE

Skills

• Excellent communication skills
• Organizational skills
• Decision-making skills
• Customer service orientation
• Interpersonal skills
• Knowledge of medical terminology and WC regulations
• Knowledge of liens and Medicare Set-Asides
• Ability to travel

Benefits

• Salary is commensurate with experience and credentials
• Total Rewards package including 401(k) with employer match up to 8%, health, dental, and vision insurance, life and disability coverage, generous PTO, Paid Sick Leave, and paid parental leave in addition to state-mandated leave
• Discretionary bonuses