Claims Specialist

Groundworks•Virginia Beach, VA

2d•Onsite

About The Position

The Claims Specialist is responsible for managing an assigned portfolio of workers' compensation claims and serving as the primary liaison for injured employees throughout the claim lifecycle. This role independently coordinates claim activity from initial injury reporting through resolution by partnering with third-party administrators (TPAs), insurance carriers, Human Resources, Payroll, branch leadership, medical providers, Safety, and Legal to facilitate timely claim handling, support employee recovery, and achieve successful return-to-work outcomes. The Claims Specialist exercises independent judgment in managing day-to-day claim activity, identifying and escalating high-risk or complex issues, and ensuring compliance with applicable workers' compensation regulations and company policies. This position plays a critical role in enhancing the employee experience, reducing claim duration, supporting operational continuity, and contributing to the organization's overall workers' compensation strategy.

Requirements

4+ years of experience in workers' compensation claims administration, insurance claims, risk management, Human Resources, Safety, or a related field.
Demonstrated knowledge of workers' compensation claims administration, medical terminology, regulatory requirements, and industry best practices.
Ability to independently manage a portfolio of claims while exercising sound judgment, prioritizing competing demands, and delivering exceptional customer service.
Strong analytical skills with the ability to identify claim trends, evaluate risk, recommend solutions, and escalate complex issues appropriately.
Excellent interpersonal and relationship-building skills with the ability to influence and collaborate effectively across all levels of the organization and with external business partners.
Strong verbal and written communication skills with the ability to communicate complex claim information clearly, professionally, and empathetically.
Excellent organizational skills with the ability to manage multiple priorities while maintaining accuracy, attention to detail, and regulatory compliance.
Proficiency with Microsoft Office Suite and the ability to effectively utilize claims management systems, HRIS platforms, and reporting tools.
Ability to maintain confidentiality while handling highly sensitive employee, medical, and legal information.

Nice To Haves

Experience working with third-party administrators, insurance carriers, or workers' compensation programs preferred.
Experience coordinating return-to-work programs is preferred.

Responsibilities

Manage an assigned portfolio of workers' compensation claims from initial injury reporting through claim resolution while ensuring timely and effective claim progression.
Serve as the primary business partner and point of contact for injured employees throughout the claims process, providing proactive communication regarding claim status, medical treatment, work restrictions, wage replacement benefits, and return-to-work expectations.
Partner directly with third-party administrators, insurance carriers, medical providers, Payroll, Human Resources, Safety, and operational leadership to facilitate timely claim resolution and positive employee outcomes.
Evaluate claim activity, identify potential barriers to resolution, and proactively recommend solutions to improve claim outcomes and employee experience.
Coordinate medical treatment, monitor employee recovery, and facilitate successful return-to-work efforts in partnership with operational leadership and Human Resources.
Review claim documentation for completeness, accuracy, and regulatory compliance while ensuring appropriate documentation is maintained throughout the claim lifecycle.
Monitor claim trends, identify emerging risks, and escalate complex, litigated, catastrophic, or high-exposure claims to the Claims Manager.
Conduct claim investigations by gathering documentation, coordinating witness statements, and partnering with internal stakeholders to support claim resolution.
Support litigation management by coordinating documentation requests, maintaining claim records, and partnering with internal and external legal resources.
Analyze claim activity and contribute to reporting, trend analysis, and process improvement initiatives designed to reduce claim costs, improve employee experience, and enhance operational effectiveness.
Recommend opportunities to improve claims administration processes, employee communication, and return-to-work practices.
Maintain confidentiality while exercising sound judgment in handling sensitive employee, medical, and business information.
It is an essential function of this role that this individual reliably and regularly report to work each working day.
Perform other duties as necessary or assigned.