Complex Claims Specialist - Workers' Compensation (Southeast)

Job Summary

Seeking an experienced and highly skilled Complex Claims Specialist to join a Workers' Compensation team. This is a fully remote, full-time position that involves managing a caseload of high-exposure and complex Workers' Compensation claims. The ideal candidate will have extensive experience in handling litigated claims, a strong understanding of Workers' Compensation regulations, and the ability to work independently in a fast-paced environment. This role may require occasional travel for mediations, training, and departmental meetings.

Compensation Package

• Salary Range: $100,000 - $125,000 per year (up to $135,000 for highly qualified candidates)
• Benefits:
  • 5% match $1 for $1 on 401(k)
  • 6 weeks of paternity leave
  • 6% average merit increase (no cap on wage per position)
  • $750 individual employer-paid HSA contribution and $1,500 for a family
  • 23 days of PTO and 4 floating holidays
  • Comprehensive medical (PPO/HDHP), vision, dental (with orthodontia coverage), disability, and life insurance
  • Paid parental leave
  • Education Assistance Program with 100% upfront tuition reimbursement for approved degree programs after 6 months of service
  • Service Recognition Program with monetary awards for vacations every 5 years of employment
  • Wellness initiatives, including fitness center and Weight Watchers reimbursement programs
  • Voluntary benefits such as accident, critical illness, and hospital indemnity coverage
  • Employee discount and rewards program for travel, tickets, electronics, and more

Responsibilities

• Investigate coverage, determine compensability, and manage a caseload of high-exposure Workers' Compensation claims involving catastrophic injuries and complex cases.
• Establish and update reserves throughout the life of the claim to reflect exposure and document supporting rationale.
• Resolve claims within authority and provide case value recommendations to senior leadership for cases exceeding authority limits.
• Participate in reserving, pricing, and strategy discussions with senior leadership.
• Collaborate with outside defense counsel to manage litigated files effectively, adhering to established litigation management guidelines.
• Partner with medical providers, customers, and injured workers to facilitate appropriate medical treatment and ensure timely submission of medical bills.
• Ensure compliance with state and federal Workers' Compensation regulations.
• Deliver exceptional customer service to policyholders, agents, injured workers, medical providers, legal representatives, and vendors.
• Follow escalation and reporting requirements for claims with significant exposure.
• Develop creative resolution strategies for complex cases, utilizing internal and external resources effectively.
• Maintain accurate and compliant documentation of claim files.
• Identify subrogation opportunities and potential fraud requiring Special Investigations Unit (SIU) involvement.
• Train new team members and act as a technical resource for less experienced claims representatives.
• Maintain continuing education requirements.

Qualifications/Requirements

• Education: Bachelor’s degree required. Industry designations such as AIC, SCLA, or CPCU are a plus.
• Licensing: Active adjuster license required, with confirmation of home state license.
• Experience:
  • Minimum of 10 years of experience handling complex Workers' Compensation claims.
  • Jurisdictional experience in AL, FL, GA, KY, LA, NC, and SC is preferred.
  • Experience with structured settlements and Medicare Set-Asides.
• Skills:
  • Strong analytical, organizational, and time management skills.
  • Excellent written and verbal communication skills.
  • Ability to work independently and meet deadlines in a virtual office environment.
  • Strong negotiation skills and the ability to develop creative resolution strategies.
  • Proficiency in MS Word, Excel, and internet applications.
  • Highly detail-oriented with the ability to prioritize tasks effectively.
  • Advanced verbal and written communication skills for interacting with internal and external stakeholders.

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