Claims Specialist - Workers Compensation
About The Position
As a member of the Claims team, the Claims Specialist uses Workers Compensation claims knowledge to independently investigate, evaluate, and resolve assigned claims, including more complex claims, to achieve appropriate outcomes. The role administers and resolves high-risk management-expectations claims in a timely manner and in accordance with legal statutes, policy provisions, and company guidelines. The position requires knowledge of Pennsylvania Workers Compensation regulations, effective communication and customer service, and the ability to work independently while managing multiple tasks. The role may involve business travel of approximately less than 10%.
Requirements
- Working knowledge of Workers Compensation regulations for Pennsylvania jurisdiction.
- Bachelor’s degree and/or four or more years of equivalent work experience in an insurance-related industry.
- License required, or ability to obtain a license within 90 days of employment in mandated states.
- Familiarity with medical terminology and/or Workers’ Compensation.
- Strong organizational skills and demonstrated ability to work independently and manage multiple tasks simultaneously.
- Critical thinking skills demonstrating analysis, judgment, sound decision-making, and attention to detail.
- Strong verbal and written communication and customer service skills gained through previous work experience.
- Computer literacy, including working knowledge of Microsoft Office products such as Word, Excel, and PowerPoint.
- Ability to travel for business purposes, approximately less than 10%.
Nice To Haves
- Associate in Claims (AIC) designation or similar professional designation.
Responsibilities
- Promptly investigate assigned claims with minimal supervision, including claims of a more complex nature.
- Determine coverage, compensability, potential subrogation recovery, and second injury fund eligibility when applicable.
- Alert the Supervisor and Special Investigations Unit to potentially suspect claims.
- Ensure timely denial or payment of benefits in accordance with jurisdictional requirements.
- Establish appropriate reserves within granted authority, document the rationale, and maintain and adjust reserves over the life of each claim to reflect changes in exposure.
- Negotiate claim settlements within granted authority.
- Establish and implement action plans for case resolution, including medical and disability management, litigation management, negotiation, and disposition.
- Work collaboratively with Lodestar nurse professionals to develop and execute return-to-work strategies.
- Select and manage service vendors to balance allocated expense and loss outcomes appropriately.
- Maintain working knowledge of jurisdictional requirements and applicable case law for each state serviced.
- Demonstrate technical proficiency through timely, consistent execution of best claims practices.
- Communicate effectively, verbally and in writing, with internal and external parties about claims and account issues.
- Provide a high degree of customer service to clients, including face-to-face interactions during claims reviews, stewardship meetings, and similar account-specific sessions.
- Authorize treatment based on protocols established by statute or the Lodestar Managed Care department.
- Assist Lodestar clients by suggesting panel provider information in accordance with applicable state statutes.
- Follow the Company’s Code of Business Conduct and Ethics and apply relevant compliance policies, procedures, standards, and laws in performing work.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
