Workers Compensation, Claims Specialist II

Nationwide•Iowa City, IA

18h•$69,500 - $129,000•Hybrid

About The Position

This role is for a Claims Specialist II within Nationwide's Property and Casualty team, focusing on workers' compensation claims. The company is a Fortune 100 company with significant annual sales, emphasizing innovation and customer value. The position requires a strong desire to provide prompt, courteous, and fair service, with skills in investigation, negotiation, and communication. The Claims Specialist will handle workers' compensation claims from multiple states, determining compensability, entitled benefits, average weekly wage, and benefit rate according to state statutes. Key responsibilities include promoting exemplary customer service, establishing timely and appropriate case reserves, managing claims to resolution, and frequent communication with customers, injured workers, and medical providers.

Requirements

Three to five years prior experience in workers’ compensation claims.
Advanced knowledge of insurance theory and practices, insurance contracts and their application.
Proven knowledge of insurance contracts, medical terminology, workers compensation, and the legal aspects of court procedures affecting legal liability for all lines of insurance.
Knowledge of claims systems.
Excellent customer focus and proven ability to proactively meet customer needs.
Analytical skills necessary to make decisions and resolve conflict in such areas as application of coverage to submitted claims, application of laws of jurisdiction to investigation facts, application of policy exclusions and exceptions.
Ability to establish repair requirements and cost estimates for extensive losses and serves as a subject matter expert on respective claims projects.
Proven organizational skills to effectively prioritize increased and more complex workloads.
Demonstrates strong but flexible standards to balance the conflicting demands of the position.
Excellent written and verbal communication skills necessary to effectively communicate and/or negotiate with policyholders, claimants, attorneys, agents, and general public.
State licensing where required.
Successful completion of required/applicable claims certification training/classes.
Valid credit check and/or background check will be required as part of the selection process.

Nice To Haves

Undergraduate studies in business administration or related field preferred and/or relevant Workers’ Compensation experience.
Familiarity with claims processing and claims best practices and procedures preferred.
General knowledge of insurance theory and practices, insurance contracts and their application.
Demonstrated leadership capabilities to effectively train, coach, and provide feedback to less experienced associates.

Responsibilities

Provides appropriate notices to policyholders and injured employees according to applicable state workers’ compensation statute and obtains appropriate forms and documentation to verify employee/employer relationship and average weekly wage.
Completes and files appropriate first and second notice of injury as required by individual state workers’ compensation statute and electronic data interchange reporting regulations.
Employs appropriate claims management techniques and direct intervention (e.g., independent medical examinations, referral for rehabilitation, utilization review, etc.) to manage each claim.
Maintains contact with policyholders and injured worker and pursues return to work initiatives.
Utilizes effective Telephonic Nurse Case Manager or Field Nurse Case Management services to assist with managing medical care and return to work activities.
Consults with internal Claims Medical Specialist for future care needs and issues of life expectancy.
Evaluates exposures, manages ongoing case reserves in alignment with best practices and negotiates settlements as appropriate.
Documents significant activity and decisions in each claim via on-line claim system.
Evaluates all pertinent information and works in conjunction with claimant/client to pursue most appropriate claims resolution.
Investigates and pursues third party recoveries and any applicable deductibles.
Manages litigated claim issues in alignment with Best Claims Practices.
Obtains appropriate litigation budgets and develops appropriate power of attorney in partnership with counsel.
Manages litigation expenses of Nationwide Trial Division or approved outside counsel.
Manages assigned claims with little to no direction and oversight.
Makes decisions within delegated authority as outlined in company policies and procedures.
Adheres to high standards of professional conduct consistent with the delivery of superior service.
Submits severe incident reports, reinsurance reports and other information to home office, claims management, and underwriting.
Reviews files for Medicare reporting obligations and submits appropriate Medicare query, Ongoing responsibility for Medicals (ORM) and Total Payment Obligation to claimant (TPOC) reports.
Responsible for claims involving Medicare Set Aside at time of settlement and which may be funded by a structured settlement.
Partners with Special Investigative Unit (SIU) and Subrogation to identify fraud and subrogation opportunities.
Delivers a positive customer service experience to all internal, external, current and prospective Nationwide customers.
May periodically conduct customer/account visits to review reserves and discuss status of significant claims.
May also present educational workshops to client personnel.
May perform other responsibilities as assigned.