Claims Specialist II, Workers Compensation

Nationwide•Iowa City, IA

4d•$69,500 - $103,500•Remote

About The Position

Nationwide’s Property and Casualty team is seeking a Claims Specialist to investigate and handle medical and/or loss-of-time workers’ compensation claims from multiple states. The specialist determines compensability, entitled benefits, average weekly wage, and benefit rate under applicable state workers’ compensation statutes, while providing prompt, courteous, fair service and managing claims toward appropriate resolution. The role involves establishing timely and appropriate case reserves, communicating frequently with customers, injured workers, and medical providers, and balancing customer satisfaction with cost management. The position handles assigned claims with little to no direction or oversight, making decisions within delegated authority and following company policies and procedures. It partners with policyholders, injured workers, medical providers, counsel, internal claims teams, and other units to support medical care, return-to-work efforts, investigations, settlements, litigation, recovery, and compliance reporting. The role is remote and may be filled within any of the lower 48 U.S. states. It reports to a Supervisor/Manager and has no direct or indirect reports.

Requirements

Three to five years of prior workers’ compensation claims experience.
Undergraduate studies in business administration or a related field preferred, and/or relevant workers’ compensation experience.
State licensing where required.
Successful completion of required or applicable claims certification training and classes.
Advanced knowledge of insurance theory and practices, insurance contracts, and their application.
Knowledge of insurance contracts, medical terminology, workers’ compensation, and legal aspects of court procedures affecting legal liability for all lines of insurance.
Knowledge of claims systems.
Analytical skills to make decisions and resolve conflicts involving coverage, jurisdictional law, investigation facts, and policy exclusions and exceptions.
Organizational skills to prioritize increased and more complex workloads.
Excellent written and verbal communication skills to communicate and negotiate effectively with policyholders, claimants, attorneys, agents, and the general public.
Ability to balance competing demands with strong but flexible standards.
Demonstrated leadership capabilities to train, coach, and provide feedback to less experienced associates.
Ability to work irregular hours and travel, including possible overnight travel.
Availability to work catastrophes, including travel to catastrophe sites and performing multiple on-site responsibilities or working extended periods.
Ability to sit and use a telephone and personal computer for extended periods.

Nice To Haves

Familiarity with claims processing and claims best practices and procedures.
Undergraduate studies in business administration or a related field.
Relevant workers’ compensation experience.
Ability to establish repair requirements and cost estimates for extensive losses and serve as a subject matter expert on claims projects.

Responsibilities

Provide appropriate notices to policyholders and injured employees under applicable state workers’ compensation statutes, and obtain documentation verifying the employee/employer relationship and average weekly wage.
Complete and file first and second notices of injury as required by state statutes and electronic data interchange reporting regulations.
Use claims management techniques and direct intervention, including independent medical examinations, rehabilitation referrals, and utilization review, to manage claims.
Maintain contact with policyholders and injured workers and pursue return-to-work initiatives; coordinate effective telephonic or field nurse case management services as appropriate.
Consult internal Claims Medical Specialists about future care needs and life-expectancy issues.
Evaluate exposures, manage case reserves in alignment with best practices, negotiate settlements as appropriate, and document significant claim activity and decisions in the online claim system.
Evaluate pertinent information and work with claimants and clients to pursue appropriate claims resolutions.
Investigate and pursue third-party recoveries and applicable deductibles, using internal recovery resources, outside counsel, trial division, lien notices, field assistance, or outside experts as appropriate.
Manage litigated claim issues in alignment with Best Claims Practices, obtain appropriate litigation budgets, develop powers of attorney with counsel, and manage litigation expenses.
Make decisions within delegated authority, manage assigned claims with little to no direction or oversight, and maintain professional conduct and superior service standards.
Submit severe incident reports, reinsurance reports, and other information to the home office, claims management, and underwriting.
Review files for Medicare reporting obligations and submit applicable Medicare queries, Ongoing Responsibility for Medicals reports, and Total Payment Obligation to Claimant reports.
Handle claims involving Medicare Set-Asides at settlement, which may be funded by structured settlements.
Partner with the Special Investigative Unit and Subrogation to identify fraud and subrogation opportunities.
Provide a positive customer-service experience to internal and external customers, including current and prospective Nationwide customers.
Periodically conduct customer or account visits to review reserves and significant claim status, and present educational workshops to client personnel as needed.
Perform other responsibilities as assigned.

Benefits

Medical insurance
Dental insurance
Vision insurance
Life insurance
Short- and long-term disability coverage
Paid time off: newly hired associates receive a minimum of 18 days per full calendar year, prorated quarterly based on hire date
Nine paid holidays
Eight hours of Lifetime paid time off
Eight hours of Unity Day paid time off
401(k) with company match
Company-paid pension plan
Business casual attire