Claims Specialist Workers Compensation

UFG is seeking to add an entry-level Claims Specialist I to our high performing Workers Compensation Claim Specialization team. The role is responsible for verifying applicable coverage conducting timely and thorough research of the facts of a loss analyzing compensability and evaluating benefits for accurate reserves. This role will primary be responsible for Medical Only type of claims and may also have responsibility for low complexity low severity indemnity claims in accordance with claims best practices. The following Essential Duties & Responsibilities defines the growth trajectory of knowledge and skills a successful candidate will be given opportunity to develop.

The Claims Specialist I WC role demonstrates a desire to learn and grow promotes a positive work environment and embraces a service-oriented mindset in support of internal and external customers. This role requires good communication skills attention to detail and the ability to handle multiple tasks efficiently and effectively.

Essential Duties & Responsibilities:

• Review claim assignments to determine policy coverage compensability of a claimed injury or illness and facilitation of medical indemnity and other statutory workers compensation benefits. If a coverage issue is relevant review facts with a designated leader or mentor to determine a proper plan of action.
• Make prompt meaningful contact with insureds and their employees to research facts by conducting interviews; securing understanding and synthesizing information from relevant documents; and identifying other relevant parties to a claim.
• Establish rapport and an outcome focused relationship with insureds and their employees as well as other internal and external stakeholders through consistent on-going contact throughout the recovery process and claim resolution.
• Request and analyze medical records to determine compensability according to evidence-based causation by jurisdiction.
• Interact with medical providers to clearly define medical causation and establish treatment plans focused on recovery.
• Promptly and supportively inform insureds and employees as well as other stakeholders of coverage and compensability decisions.
• Support stay-at-work or return-to-work opportunities for insureds and their employees.
• Identify subrogation potential and document evidence in support of subrogation. Partner with the Technical Leader on increasing knowledge of the subrogation mechanism.
• Identify potential Medicare eligibility and comply with all Medicare Secondary Payor requirements of law.
• Assess and periodically re-assess the nature and severity of injury or illness. Design a plan of action focused on recovery and resolution in accordance with claims best practice guidelines by jurisdiction.
• Assess and periodically re-assess claim file reserves for adequacy. This will be achieved through understanding medical diagnoses and care plan developments; thorough analysis of wage information and accurate calculations of indemnity benefits; and by securing and providing job descriptions specific to the employee to medical providers.
• Execute all technical claim handling functions such as documenting facts within the claims management system in a consistent concise and clear manner; make timely decisions and promptly communicate decisions to stakeholders; process accurate benefit payments; and seek opportunities to mitigate claim handling expenses.
• Proactively seek resolution of claims by defining stakeholder outcome expectations early and often. With the support of the Technical Leader negotiate settlements of low to medium complexity claims.
• Comply with statute specific claims handling practices and reporting requirements.
• Inform underwriting of increased hazards or unusual circumstances concerning a risk/policy exposure.
• Participate in internal and external continuing education opportunities to maintain licensure and develop claim handling skills and abilities.
• Demonstrate a supportive attitude and presence within the team by adapting well to change in process or procedure. Share innovative ideas to improve work product and outcomes. Take initiative to identify and learn about areas of professional development. Proactively seek out opportunities to collaborate with peers.
• Demonstrate interest in ones own career development.

Job Specifications:

Education:

• High school diploma required.
• Post-Secondary education or Bachelors degree is considered advantageous.

Licensing/Certifications/Designations:

• Meet the appropriate state licensing requirements to handle claims.
• Within 2 years of hire complete the Workers Recovery Professional (WRP) certification program.

Experience:

• 3yearsofgeneralwork experience.

Knowledge:

• Basic knowledge of insurance medical and/or legal concepts is considered advantageous.

Skills and Abilities:

• Service-Oriented Mindset
• Clear and Concise Communication
• Analytical and Critical Thinking
• Attitude of Collaboration and Curiosity
• Proactive Decision-making and Problem-solving
• Time management and Sense of Service Urgency

Working Conditions:

• Working remote from home or general office environment.
• Occasionally the job requires working irregular hours.
• Infrequent overnight travel and weekend hours may be required.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this job. It is not designed to contain or be interpreted as a comprehensive list of all duties responsibilities and skills required. Additional task and requirements may be assigned as necessitated by business need. UFG retains the right to modify the description of this job at any time.

Required Experience:

Unclear Seniority