Claim Specialist

General Summary

The Claim Specialist I investigates, evaluates, negotiates, and resolves lost time claims within settlement and reserving authority up to stated maximum. (Supervisor will determine actual individual authority up to the stated maximum).

• 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. Maintains contact throughout the life of the file as needed.
• 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.
• 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

• One to three years of lost time claim handling experience preferred. Bachelor’s Degree preferred.
• Computer skills, Word, Excel and Image Right preferred.
• Must have 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 and other resources wisely.
• Must have the ability to work effectively with other organizational team members.