Claims Specialist, Lead Workers Compensation (or Claims Specialist II) - Remote

This role can be filled anywhere - remote, with the expectation that they will support California Workers Compensation Claims.

Ideal candidates will have:

• Strong understanding of Workers Compensation Claims - loss time
• California jurisdictional experience
• Experience in other jurisdictions will be considered based on prior skills/qualifications.
• ClaimsCenter experience is a plus.

There are two available positions: 1 we are filling at the Spec III (F4 level) and 1 at the Spec II (E4 level).

Job Description Summary

Do you have a strong desire to provide prompt, courteous and fair service to customers? Are you a skilled investigator, negotiator and communicator? If you thrive in an environment where you can problem-solve workers’ compensation claims resolution, while following processes that provide fair resolution, customer satisfaction and cost management, then we want to hear from you!

As a Claims Specialist, you’ll investigate, coordinate and process medical and indemnity workers compensation claims involving multiple states to determine compensability, entitled benefits, average weekly wage and benefit rate, per the applicable State Workers’ Compensation Statute. We’ll count on you to promote and provide exemplary customer service. Key to success will be your ability to establish timely and appropriate case reserves according to best practices and managing claims to appropriate resolution. You’ll provide timely and accurate claims administration according to contract and/or client service plan and within applicable state laws.

Job Description

Key Responsibilities:

• Completes state and other regulatory reports/forms to include Electronic Data Interchange (EDI) forms as required by each State Workers’ Compensation Statute or State Regulatory Rules.

• Employs appropriate claims management techniques and directs intervention (i.e. 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 decision in each claim via on-line claim system.

• Manages litigated claim issues according to best claims practices. Obtains appropriate litigation budgets and develops appropriate power of attorney in partnership with counsel and manages litigation expenses of Nationwide Trial Division or approved outside counsel. Manages claims involving MSA's at time of settlement and which may be funded by a structured settlement.

• Evaluates all pertinent information and works in conjunction with claimant/client to achieve the most appropriate claims resolution. Assists with assignment of new claims. Delivers a positive customer service experience to all internal, external, current and prospective Nationwide customers.

• Investigates and pursues third party recoveries and any applicable deductibles. May utilize the services of Nationwide recovery unit, and/or partner with designated outside counsel/trial division, or by giving notice of lien to plaintiff counsel handling third party litigation. Claim Zone Field assist referrals and/or outside consulting expert may be utilized to gather, obtain and secure critical information.

• Opens, closes and adjusts reserves according to company practices designed to ensure reserve adequacy. Recommends special reserves where necessary.

• Maintains current knowledge of court decisions which may impact the claims function; current principles and practices in the claims function; material damage techniques and repair technology innovations; and policy changes and modifications. May be required to maintain knowledge of other functions within assigned discipline. This may require attendance at various seminars or training sessions. Consults claims staff and defense counsel for discovery processes, suit file/trial strategy as related to case-specific issues.

• Mentors less experienced claims associates and assists with training/presentations as assigned by claims management. Assists with the training and development of other claims associates. May be unit leader when Manager is out of the office.

• Referral point for claims issues from team, other claims units, customers and legal. May serve as venue specific or topic specific expert to unit and serve as a ready resource to Claims Specialists for guidance.

• Reviews files for Medicare reporting obligations and submits appropriate Medicare query. Ongoing responsibility for Medicals and total payment obligation to claimant reports.

• Provides appropriate notices to policyholders and injured employee on complex claims according to applicable state workers compensation statutes and obtains appropriate forms and documentation to verify employee/employer relationship and average weekly wage. Completes and files appropriate first and/or second report(s) of injury as required by individual state workers’ compensation statute and EDI reporting regulations.

• Assists with or is assigned special projects for completion under direction of Claims Manager. Will serve as designated project representative for new system enhancements/implementations/pilot projects.

• Conducts 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.

Reporting Relationships: Reports to Supervisor/Manager.

Typical Skills and Experiences:

Education: Undergraduate degree or equivalent experience preferred. Advanced degrees in law or related discipline desirable.

License/Certification/Designation: Successful completion of required claims certification schools/courses. Professional development such as IIA or CPCU preferred. State licensing where required.

Experience: Five years’ work experience in workers compensation claims. Successful completion of formal claims training program per business unit standards.

Knowledge, Abilities and Skills: Detailed knowledge of medical, legal and workers compensation terminology, state regulations to include EDI reporting obligations, claims processes, best practices, and customer relationship management. Advanced knowledge of insurance theory and practices, insurance contracts and their application. Familiarity with claims processing and claims best practices and procedures preferred. 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. Proven ability to meet customer needs and provide exemplary service by informing customers of the claims process and ensuring a positive customer experience. Command of all skills necessary for verbal and written communication. Ability to operate personal computer to input and retrieve data via on-line claims administration system. Ability to set work priorities and to plan and executive work within deadlines. Ability to analyze claim information and statistical data. Ability to perform mathematical calculations necessary to set reserves. Ability to analyze and interpret medical reports. Ability to negotiate effective resolution of claims issues, including settlements. May demonstrate leadership qualities and/or technical expertise critical to the role and the unit. Demonstrate actions consistent with a positive Associate engagement, and actions consistent with the Nationwide Values. Able to present complex information in a manner easily understandable to other business units or associates with less experience. Can handle multiple project assignments in addition to and simultaneous to claim handling duties. Possesses ability to teach, train and motivate others.

Other criteria, including leadership skills, competencies and experiences may take precedence.

Staffing exceptions to the above must be approved by the hiring manager’s leader and HR Business Partner.

Values: Regularly and consistently demonstrates the Nationwide Values.

Job Conditions:

Overtime Eligibility: Exempt (Not Eligible)

Working Conditions: Normal office environment. May require ability to sit and use telephone and personal computer for extended periods of time. Must be willing to work irregular hours and to travel with possible overnight requirements. Must be available to work catastrophes (CAT) requiring travel to CAT site with multiple on-site responsibilities and/or for extended periods of time. Extended and/or non-standard hours as required.

ADA: The above statements cover what are generally believed to be principal and essential functions of this job. Specific circumstances may allow or require some people assigned to the job to perform a somewhat different combination of duties.

Credit/Background Check: Due to the fiduciary accountabilities within this job, a valid credit check and/or background check will be required as part of the selection process.

#claimsSmoke-Free Iowa Statement: Nationwide Mutual Insurance Company, its affiliates and subsidiaries comply with the Iowa Smokefree Air Act. Smoking is prohibited in all enclosed areas on or around company premises as well as company issued vehicles. The company offers designated smoking areas in which smoking is permitted at each individual location. The Act prohibits retaliation for reporting complaints or violations. For more information on the Iowa Smokefree Air Act, individuals may contact the Smokefree Air Act Helpline at 888-944-2247.