Complex Claims Specialist - Workers' Compensation (Remote)

Job Summary

Seeking an experienced Complex Claims Specialist with a strong background in handling complex Workers’ Compensation claims. This role involves managing a caseload of high-severity claims, including catastrophic injuries, across multiple jurisdictions. The ideal candidate will possess extensive knowledge of Workers’ Compensation regulations, laws, and best practices. This is a 100% remote position with occasional travel required for mediations, training, and departmental meetings.

Compensation Package

• Salary Range: $100,000 - $125,000 (depending on experience)
• Competitive benefits package, 401(k), paid time off, professional development opportunities, etc.

Responsibilities

As a Complex Claims Specialist, your key responsibilities will include:

• Investigating coverage, determining compensability, and managing high-exposure Workers’ Compensation claims involving catastrophic injuries and complex cases.
• Establishing and updating reserves throughout the claim lifecycle to reflect exposure, with documented rationale.
• Resolving claims within authority limits and making case value recommendations to senior leadership for cases exceeding authority.
• Collaborating with outside defense counsel to manage litigated files in accordance with established guidelines.
• Partnering with medical providers, customers, and injured workers to facilitate appropriate medical treatment and ensure timely submission of medical bills.
• Ensuring compliance with state and federal Workers’ Compensation regulations.
• Providing exceptional customer service to policyholders, agents, injured workers, medical providers, legal teams, and vendors.
• Developing creative resolution strategies for complex cases, utilizing internal and external resources effectively.
• Documenting claim files in accordance with company and regulatory guidelines.
• Identifying subrogation potential and red flags requiring Special Investigations Unit (SIU) involvement.
• Training new team members and acting as a technical resource for less experienced claims representatives.
• Maintaining continuing education requirements.

Qualifications/Requirements

Knowledge and Experience:

• Active adjuster license required.
• Minimum of 10 years of experience handling complex Workers’ Compensation claims.
• Multi-state experience in jurisdictions such as California, Arizona, Colorado, Wyoming, Texas, and Oklahoma (willingness to learn additional jurisdictions is required).
• Proficiency in structured settlements and Medicare Set-Asides.
• Strong negotiation, analytical, organizational, and time management skills.
• Ability to work independently in a fast-paced, virtual office environment.
• Advanced verbal and written communication skills for interacting with internal and external stakeholders.
• Proficiency in MS Word, Excel, and internet applications.
• Highly detail-oriented with the ability to prioritize tasks effectively under pressure.

Education:

• Bachelor’s degree required.
• Industry designations such as AIC, SCLA, or CPCU are a plus.

Disclaimer: Please note that this job description may not cover all duties, responsibilities, or aspects of the role, and it is subject to modification at the employer's discretion. 

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