Complex Claims Specialist - Workers' Compensation

Job Summary

Seeking a highly skilled and experienced Complex Claims Specialist to join a Workers' Compensation team. This is a full-time, 100% remote position with occasional travel required for mediations, training, and departmental meetings. The ideal candidate will have a strong background in handling complex and high-severity Workers' Compensation claims across multiple jurisdictions. This role offers the opportunity to work in a fast-paced, collaborative environment while contributing to the success of a leading insurance organization.

Compensation Package

• Salary Range: $100,000 - $125,000 per year
• 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 a caseload of high-exposure Workers' Compensation claims involving catastrophic injuries and complex cases.
• Establishing and updating reserves to reflect claim exposure and documenting supporting rationale.
• Resolving claims within authority and making case value recommendations to senior leadership for cases exceeding authority.
• Collaborating with outside defense counsel to manage litigated files effectively.
• 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 issues and utilizing internal and external resources effectively.
• Documenting claim files in accordance with company and regulatory guidelines.
• Identifying subrogation potential and red flags requiring 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 New York, New Jersey, Maine, New Hampshire, Vermont, Massachusetts, Pennsylvania, Rhode Island, Connecticut, Delaware, Maryland, Washington DC, West Virginia, Virginia, North Carolina, and South Carolina (or willingness to learn additional jurisdictions).
• Proficiency in structured settlements and Medicare Set-Asides.
• Strong analytical, organizational, and time management skills.
• Excellent written and verbal communication skills.
• Ability to work independently in a virtual office environment and meet deadlines.
• Strong negotiation skills and the ability to prioritize tasks effectively.
• Proficiency in MS Word, Excel, and internet applications.
• Highly detail-oriented with the ability to execute sound judgment in sensitive situations.

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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