Claims Specialist

New Mexico Mutual Casualty Company•Albuquerque, NM

20d

About The Position

The Claims Specialist provides expert claim handling for serious and complex workers’ compensation insurance claims, including coverage, compensability, investigation, evaluation, negotiation, litigation management, and resolution. The role handles claims under applicable law, corporate policy, and best practices, with a focus on quality claim handling, service excellence, and indemnity and expense management. The specialist also serves as a technical resource to claims professionals, business partners, policyholders, and other stakeholders. The position evaluates claim exposure and manages claim-related activity, including medical care coordination, legal counsel assignments, return-to-work strategies, reserves, benefit payments, litigation, settlements, documentation, and compliance. It also analyzes claims for trends and process improvements, mentors junior adjusters, supports Claims Managers as directed, and identifies and reports suspected insurance fraud. The role operates under general office conditions with light physical demands and occasional lifting. Employees follow safety and building-security rules, help maintain safe and efficient operating conditions, work in a drug-free environment subject to pre-employment and post-work-related-accident drug testing, and may be exposed to VDT screens.

Requirements

Bachelor’s degree from an accredited college or university.
At least 5 years of serious workers’ compensation claims experience.
At least 10 years of claims-handling experience.
State-required adjuster’s license.
Demonstrated proficiency in applying state statutes, related case law, and company claims standards, policies, and procedures.
Above-average knowledge and ability to apply case law to claim-handling practices.
Effective communication and collaborative skills, and the ability to maintain positive working relationships.
Adherence to the company’s values and mission: Service Excellence, Trust, Ownership, One team, and Boldness in thought and action.

Nice To Haves

Related professional certifications are preferred.

Responsibilities

Evaluate, analyze, and determine compensability, causation, offsets, and exposure for serious and complex workers’ compensation claims in accordance with applicable law, corporate policy, best practices, and prescribed authorities.
Verify claim information, document claim history, take recorded statements from workers and witnesses, identify subrogation opportunities, and coordinate medical care.
Document all claim activities in the claim management system.
Manage outside legal counsel assignments, return-to-work strategies with policyholders, medical case-management strategies with nurse case managers, and other expert assignments.
Set and monitor reserves, issue benefit checks in accordance with statutory requirements, and apply state statutes, case law, and company claims standards, policies, and procedures.
Ensure statutory and benefit payments are timely and accurate and meet established time frames and guidelines.
Prepare for and participate in mediation conferences and authorized legal or regulatory proceedings before regulatory agencies and courts.
Maintain diaries on open claims, document relevant information to provide clear event histories and audit trails, and set review dates based on claim complexity or standard review criteria.
Assess and report litigation involving significant financial exposure, case-law precedent, or reputational risk.
Identify claims that may be suitable for full and final settlement and negotiate settlements or coordinate them with authorized outside legal counsel.
Analyze claims for trends and opportunities to improve policies, procedures, and controls, and prepare related reports.
Mentor junior adjusters and support Claims Managers as directed.
Detect and report reasonable suspicions of insurance fraud involving claimants, medical or legal providers, policyholders, or other individuals related to claims.
Maintain claim records in compliance with applicable law, corporate policies, and retention schedules.
Adhere to company values and mission, and maintain positive working relationships through effective communication and collaboration.
Follow safety rules and regulations, including building security, and help ensure safe and efficient operating conditions.