Technical Claim Specialist - Workers' Compensation

Church Mutual Insurance Company, S.I.•,

19h

About The Position

Under limited supervision and in accordance with applicable state and federal laws and company best practices, the Technical Claim Specialist investigates, evaluates, and resolves complex, high-exposure and high-severity workers’ compensation claims. The role gathers and reviews claim information, determines coverage, conducts investigations, maintains customer contact, documents claim activity, sets reserves, and makes payments within the employee’s authority. It applies medical management strategies to complex, high-dollar claims and directs defense attorneys and other vendors. The specialist also identifies claims for referral to Loss Recovery Services and maintains advanced knowledge of workers’ compensation claim practices, industry trends, and jurisdictional requirements. The position manages claim strategy from investigation through resolution, including coverage and compensability decisions, exposure analysis, negotiations, reserves, litigation oversight, and reporting. It supports the development of less experienced staff through training, mentoring, and auditing, and communicates jurisdictional and regulatory developments to relevant stakeholders. The work environment is a professional office environment. The posting is tagged #LI-Remote.

Requirements

Minimum of eight years in technical insurance claim roles with increasing responsibilities.
Experience handling claims across multiple jurisdictions.
Ability to obtain and maintain state adjusting license requirements and complete continuing education requirements.
Advanced knowledge of recoveries, including subrogation, reinsurance, apportionment, and deductibles.
Advanced knowledge of second injury funds and reinsurance.
Advanced negotiation skills.
Strong listening, verbal, and written communication skills.
Ability to think independently.
Advanced knowledge of policy terminology, legal principles involving insurance, and emerging industry trends.
Effective planning and organization skills.

Nice To Haves

Bachelor’s degree preferred; equivalent education and/or experience may be considered in lieu of a degree.
Evidence of continuing education in the insurance industry.
Completion of AIC and/or CPCU.

Responsibilities

Perform claim tasks promptly and document claim files appropriately; proactively manage claim activities toward fair resolution and comply with applicable state and federal laws.
Apply jurisdictional expertise across assigned jurisdictions and incorporate regulatory changes into daily processes to maintain compliance.
Make complex coverage and compensability decisions based on gathered information; deny losses within authority with detailed explanations citing facts and statutory language.
Conduct investigations appropriate to claim type, complexity, and severity; assess exposure, compensability, and subrogation potential, and document an action plan aligned with the intended resolution strategy.
Set reserves based on the most probable claim outcome within authority; evaluate and negotiate with insureds, claimants, and claimants’ attorneys; review claim strategy with claims management as appropriate; and make accurate, timely payments within authority.
Identify and appropriately handle claims with Medicare Set Aside exposure.
Identify, assign, direct, and manage vendor partners such as experts, nurses, and defense attorneys; end assignments when vendors are no longer adding value and manage claim expenses.
Communicate professionally, courteously, and helpfully with internal and external customers, business partners, and brokers through in-person, phone, email, and other correspondence.
Coordinate and participate in training for less experienced staff; share expertise, mentor claim handlers, and support their development through auditing.
Investigate and refer identified claims to Loss Recovery Services when applicable.
Direct defense attorneys through collaboration on claim strategy and resolution; ensure compliance with litigation management guidelines and assess attorney or firm performance, results, and service value.
Conduct direct investigation, control, and settlement negotiations when outside adjusting and legal services are not necessary or available.
Attend mediations as requested.
Understand key data elements and analyze claims-related data.
Present complex claim files as requested and prepare large-loss reports under internal protocols for executive management approval.
Monitor jurisdictional case law and regulatory changes, apply them appropriately to claims, and communicate potential impacts to relevant CM Group stakeholders.