Claim Specialist III

Responsibilities

• Communicates with insureds, injured workers, agents, brokers, witnesses, attorneys, loss prevention, and underwriters to obtain and relate necessary information to determine coverage/compensability, facts of loss, and degree of liability/exposure.
• Administers the delivery of timely, appropriate and accurate indemnity and medical benefits.
• Evaluates claim exposure, negotiate and resolve claims.
• Works closely with defense counsel on litigated cases and attend mediation, arbitration, and hearings, as necessary.
• Develops litigation plan with defense counsel and tracks adherence to plan in order to control legal expenses and assure effective resolution.
• Works closely with insureds and employees making visitations and presentations as needed to facilitate partnership approach to claims handling.
• Maintains quality claim files in accordance with appropriate best practices, and other company procedures.
• Implements Managed Care strategies, coordinate rehabilitation or medical management, process bills, review all mail through Image Right, and monitor progress as appropriate.
• Interacts with State and Federal Boards and Commissions, while establishing and maintaining proper reserves, as appropriate.
• Serves as a mentor and helps prepare/train the less experienced Claim Department representatives.
• Keeps up-to-date on State laws and Company procedures relating to various claims; educates injured worker and/or insured on same.
• Prepares and presents files for Agent/Broker Reviews and Insured File Review.
• Understands medical terminology and standard medical procedures as they pertain to worker’s compensation, U. S. Longshoreman’s and Jones Act claims.
• Participates in in-house and outside training programs to keep up-to-date on relevant issues/topics.
• Maintains a working knowledge of all computer systems currently in use.
• Travels throughout States as required to handle claims inventory assigned.
• Continues education in claims through Associate in Claims or Claims Law (AEI) courses.

Requirements

• Three years of workers’ compensation lost time and medical only claim handling experience preferred.
• Bachelor’s degree preferred.
• Computer skills, Word, Excel and Image Right preferred.
• Must have a valid driver’s license.
• Strong attention to detail and strong communication skills both verbal and written.
• Adaptable/flexible and self-directed with the ability to manage time, multiple priorities and other resources wisely.
• Must have the ability to work effectively with other organizational team members.
• Core Competencies

Demonstrates expertise in workers' compensation claims handling, including evaluating claim exposure, negotiating settlements, and administering medical benefits.

Proficient in maintaining quality claim files and implementing managed care strategies while ensuring compliance with state laws and company procedures.

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