Claims Specialist II, Workers Compensation

Nationwide•Iowa City, IA

9d•$69,500 - $103,500•Remote

About The Position

Nationwide's Property and Casualty team is seeking a Claims Specialist II, Workers Compensation who is passionate about helping people protect what matters most. This role involves innovating and simplifying processes to provide the best customer value, with a focus on delivering extraordinary care. The ideal candidate will have a strong desire to provide prompt, courteous, and fair service, and possess skills in investigation, negotiation, and communication. This position offers the opportunity to problem-solve workers’ compensation claims resolution while adhering to processes that ensure fair resolution, customer satisfaction, and cost management.

Requirements

Undergraduate studies in business administration or related field preferred and/or relevant Workers’ Compensation experience.
State licensing where required.
Successful completion of required/applicable claims certification training/classes.
Three to five years prior experience in workers’ compensation claims.
Advanced knowledge of insurance theory and practices, insurance contracts and their application.
Familiarity with claims processing and claims best practices and procedures preferred.
Proven knowledge of insurance contracts, medical terminology, workers compensation, and the legal aspects of court procedures affecting legal liability for all lines of insurance.
Knowledge of claims systems.
Excellent customer focus and proven ability to proactively meet customer needs.
General knowledge of insurance theory and practices, insurance contracts and their application.
Familiarity with claims processing and claims best practices and procedures preferred.
Knowledge of insurance contracts, medical terminology, workers compensation, and the legal aspects of court procedures affecting legal liability for all lines of insurance.
Knowledge of claims systems.
Analytical skills necessary to make decisions and resolve conflict in such areas as application of coverage to submitted claims, application of laws of jurisdiction to investigation facts, application of policy exclusions and exceptions.
Ability to establish repair requirements and cost estimates for extensive losses and serves as a subject matter expert on respective claims projects.
Proven organizational skills to effectively prioritize increased and more complex workloads.
Demonstrates strong but flexible standards to balance the conflicting demands of the position.
Excellent written and verbal communication skills necessary to effectively communicate and/or negotiate with policyholders, claimants, attorneys, agents, and general public.
Demonstrated leadership capabilities to effectively train, coach, and provide feedback to less experienced associates.
Valid credit check and/or background check will be required as part of the selection process.

Nice To Haves

Other criteria, including leadership skills, competencies and experiences may take precedence.

Responsibilities

Investigate and handle medical and/or loss-of-time workers compensation claims from multiple states to determine compensability, entitled benefits, average weekly wage, and benefit rate according to applicable state workers’ compensation statute.
Promote and provide exemplary customer service.
Establish timely and appropriate case reserves aligned with Best Practices and manage claims to appropriate resolution.
Communicate frequently with customers, injured workers, and medical providers.
Provide appropriate notices to policyholders and injured employees according to applicable state workers’ compensation statute and obtain appropriate forms and documentation to verify employee/employer relationship and average weekly wage.
Complete and file appropriate first and second notice of injury as required by individual state workers’ compensation statute and electronic data interchange reporting regulations.
Employ appropriate claims management techniques and direct intervention (e.g., independent medical examinations, referral for rehabilitation, utilization review, etc.) to manage each claim.
Maintain contact with policyholders and injured worker and pursue return to work initiatives.
Utilize effective Telephonic Nurse Case Manager or Field Nurse Case Management services to assist with managing medical care and return to work activities.
Consult with internal Claims Medical Specialist for future care needs and issues of life expectancy.
Evaluate exposures, manage ongoing case reserves in alignment with best practices, and negotiate settlements as appropriate.
Document significant activity and decisions in each claim via on-line claim system.
Evaluate all pertinent information and work in conjunction with claimant/client to pursue most appropriate claims resolution.
Investigate and pursue third party recoveries and any applicable deductibles.
Manage litigated claim issues in alignment with Best Claims Practices.
Obtain appropriate litigation budgets and develop appropriate power of attorney in partnership with counsel.
Manage litigation expenses of Nationwide Trial Division or approved outside counsel.
Manage assigned claims with little to no direction and oversight.
Make decisions within delegated authority as outlined in company policies and procedures.
Adhere to high standards of professional conduct consistent with the delivery of superior service.
Submit severe incident reports, reinsurance reports, and other information to home office, claims management, and underwriting.
Review files for Medicare reporting obligations and submit appropriate Medicare query, Ongoing responsibility for Medicals (ORM) and Total Payment Obligation to claimant (TPOC) reports.
Be responsible for claims involving Medicare Set Aside at time of settlement and which may be funded by a structured settlement.
Partner with Special Investigative Unit (SIU) and Subrogation to identify fraud and subrogation opportunities.
Deliver a positive customer service experience to all internal, external, current and prospective Nationwide customers.
Periodically conduct customer/account visits to review reserves and discuss status of significant claims.
Present educational workshops to client personnel.
Perform other responsibilities as assigned.