About the Role
Our client seeking an experienced and detail-oriented Claims Specialist II to join our dynamic Workers' Compensation team. In this pivotal role, you will be responsible for managing a caseload of moderately complex workers' compensation claims from initial report through final resolution. The successful candidate will demonstrate exceptional analytical abilities, medical knowledge, and interpersonal skills while ensuring compliance with state-specific regulations and company protocols. This position offers the opportunity to make a meaningful impact on both claimant outcomes and organizational success through expert claims management.
Our Organization
Our client is a leader in the insurance industry, dedicated to providing superior coverage and exceptional claims service to our diverse client base. With a commitment to integrity, innovation, and customer satisfaction, we strive to exceed expectations in every interaction. Our Workers' Compensation department is known for its expertise, efficiency, and compassionate approach to claims handling. By joining our team, you'll become part of an organization that values professional growth, work-life balance, and collaborative problem-solving.
Core Responsibilities
Claims Management and Investigation
* Manage a designated caseload of workers' compensation claims with moderate complexity, ensuring timely and appropriate handling at all stages
* Conduct thorough investigations into claim circumstances by interviewing injured workers, witnesses, supervisors, and employers to determine compensability
* Analyze employment records, accident reports, and prior claim history to identify patterns or pre-existing conditions
* Make prompt and well-documented compensability decisions based on factual investigation and jurisdictional requirements
* Identify and pursue subrogation and third-party recovery opportunities to maximize claim cost containment
* Recognize and refer potential fraudulent claims to Special Investigation Unit following established protocols
Medical Management
* Evaluate medical documentation to assess injury severity, treatment appropriateness, and estimated recovery timelines
* Coordinate with medical case managers to ensure injured workers receive appropriate care while managing costs effectively
* Review treatment plans and authorize medical procedures in accordance with evidence-based guidelines and state regulations
* Implement early intervention strategies to facilitate optimal recovery outcomes
* Identify opportunities for independent medical examinations, physician reviews, or second opinions when appropriate
* Maintain ongoing communication with treating physicians regarding work restrictions and return-to-work opportunities
Benefit Administration
* Calculate and authorize appropriate indemnity benefits in compliance with state-specific wage calculation requirements
* Ensure timely and accurate payment of temporary total, temporary partial, and permanent disability benefits
* Monitor claim reserves regularly, making appropriate adjustments based on changing circumstances
* Track benefit duration to prevent overpayments and ensure compliance with statutory limitations
* Process medical bills promptly, applying appropriate fee schedules and medical cost containment measures
* Document all benefit calculations thoroughly with supporting rationale and reference to applicable regulations
Return-to-Work Coordination
* Develop and implement effective return-to-work strategies in collaboration with employers and medical providers
* Evaluate job descriptions and physical demands to identify suitable transitional duty opportunities
* Facilitate meaningful dialogue between injured workers and employers to overcome barriers to work resumption
* Monitor progress during transitional work assignments, adjusting plans as needed based on medical updates
* Coordinate with vocational rehabilitation specialists when permanent restrictions necessitate job modification or career change
* Document all return-to-work efforts meticulously to demonstrate good faith compliance with rehabilitation requirements
Legal and Regulatory Compliance
* Maintain comprehensive knowledge of workers' compensation laws and regulations across assigned jurisdictions
* Ensure timely filing of all state-mandated forms, reports, and documentation
* Participate effectively in mediations, hearings, and depositions as needed to support claim resolution
* Collaborate with defense attorneys to develop litigation strategies for contested claims
* Negotiate settlements within authority levels, preparing thorough settlement evaluations and recommendations
* Stay current on legislative changes and case law developments affecting workers' compensation practice
Stakeholder Communication
* Maintain regular communication with injured workers, providing clear explanations of benefits and claim processes
* Build professional relationships with employers, focusing on transparency and regular claim status updates
* Collaborate with internal departments including underwriting, premium audit, and safety services to address risk factors
* Interface effectively with healthcare providers, rehabilitation specialists, and medical case managers
* Document all communications comprehensively in the claims system to ensure continuity of service
* Respond promptly to inquiries from all stakeholders, providing accurate and helpful information
Qualifications
Education and Experience
* Bachelor's degree preferred (relevant work experience may be considered in lieu of degree)
* Minimum 3-5 years of workers' compensation claims handling experience with demonstrated progression of responsibility
* Strong working knowledge of workers' compensation laws, regulations, and benefit structures in assigned jurisdictions
* Demonstrated experience calculating indemnity