Claims Specialist II, Workers Compensation

Nationwide•Iowa City, IA

4d•$69,500 - $129,000•Remote

About The Position

Nationwide’s Claims Specialist II investigates and handles medical and/or loss-of-time workers’ compensation claims from multiple states. The role determines compensability, entitled benefits, average weekly wage, and benefit rate under applicable state workers’ compensation statutes. It provides prompt, fair, and courteous service while managing claims toward appropriate resolution, customer satisfaction, and cost management. The position establishes timely and appropriate case reserves, communicates frequently with customers, injured workers, and medical providers, and manages assigned claims with little to no direction or oversight within delegated authority. The role may involve customer and account visits to review reserves and discuss significant claims, as well as educational workshops for client personnel. It is based in a normal office environment and may require extended computer and telephone use, irregular or extended hours, and travel—including overnight travel and travel to catastrophe sites for extended periods. The position could be filled within any of the lower 48 U.S. states.

Requirements

Three to five years of prior workers’ compensation claims 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 medical terminology, workers’ compensation, and legal aspects of court procedures affecting legal liability for insurance lines.
Knowledge of claims systems.
Analytical skills to make decisions and resolve conflicts involving coverage, jurisdictional laws, investigation facts, policy exclusions, and exceptions.
Organizational skills to prioritize increased and more complex workloads.
Ability to balance conflicting demands with strong but flexible standards.
Excellent written and verbal communication skills for communicating and negotiating with policyholders, claimants, attorneys, agents, and the general public.
Demonstrated leadership capabilities to train, coach, and provide feedback to less experienced associates.
Willingness to work irregular, extended, or non-standard hours as required and to travel, including possible overnight travel and catastrophe-site assignments.
Ability to sit and use a telephone and personal computer for extended periods.
A valid credit check and/or background check is required as part of the selection process.

Nice To Haves

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

Responsibilities

Provide required notices to policyholders and injured employees under applicable state workers’ compensation statutes, and obtain forms and documentation verifying the employee/employer relationship and average weekly wage.
Complete and file required first and second notices of injury under state statutes and electronic data interchange reporting regulations.
Use claims management techniques and direct interventions, such as independent medical examinations, rehabilitation referrals, and utilization review, to manage claims.
Maintain contact with policyholders and injured workers, pursue return-to-work initiatives, and use nurse case management services to assist with medical care and return-to-work activities.
Consult internal Claims Medical Specialists on future care needs and life expectancy issues.
Evaluate exposures, manage case reserves according to best practices, negotiate settlements when 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 according to best claims practices, obtain litigation budgets, develop powers of attorney with counsel, and manage litigation expenses.
Make decisions within delegated authority and comply with company policies, procedures, and professional conduct 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 (ORM), and Total Payment Obligation to Claimant (TPOC) reports.
Handle claims involving Medicare Set Asides at settlement, including those that may be funded by structured settlements.
Partner with the Special Investigative Unit and Subrogation to identify fraud and subrogation opportunities.
Deliver a positive customer service experience to internal, external, 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, with newly hired associates receiving 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