Complex Claims Specialist WC (WEST)

Job Description

Complex Claims Specialist - Workers Compensation (Remote)

Job Summary

Seeking an experienced Complex Claims Specialist with a strong background in handling complex Workers Compensation claims. This role involves managing a caseload of high-severity claims including catastrophic injuries across multiple jurisdictions. The ideal candidate will possess extensive knowledge of Workers Compensation regulations laws and best practices. This is a 100% remote position with occasional travel required for mediations training and departmental meetings.

Compensation Package

• Salary Range: $100000 - $125000 (depending on experience)
• Competitive benefits package 401(k) paid time off professional development opportunities etc.

Responsibilities

As a Complex Claims Specialist your key responsibilities will include:

• Investigating coverage determining compensability and managing high-exposure Workers Compensation claims involving catastrophic injuries and complex cases.
• Establishing and updating reserves throughout the claim lifecycle to reflect exposure with documented rationale.
• Resolving claims within authority limits and making case value recommendations to senior leadership for cases exceeding authority.
• Collaborating with outside defense counsel to manage litigated files in accordance with established guidelines.
• Partnering with medical providers customers and injured workers to facilitate appropriate medical treatment and ensure timely submission of medical bills.
• Ensuring compliance with state and federal Workers Compensation regulations.
• Providing exceptional customer service to policyholders agents injured workers medical providers legal teams and vendors.
• Developing creative resolution strategies for complex cases utilizing internal and external resources effectively.
• Documenting claim files in accordance with company and regulatory guidelines.
• Identifying subrogation potential and red flags requiring Special Investigations Unit (SIU) involvement.
• Training new team members and acting as a technical resource for less experienced claims representatives.
• Maintaining continuing education requirements.

Qualifications/Requirements

Knowledge and Experience:

• Active adjuster license required.
• Minimum of 10 years of experience handling complex Workers Compensation claims.
• Multi-state experience in jurisdictions such as California Arizona Colorado Wyoming Texas and Oklahoma (willingness to learn additional jurisdictions is required).
• Proficiency in structured settlements and Medicare Set-Asides.
• Strong negotiation analytical organizational and time management skills.
• Ability to work independently in a fast-paced virtual office environment.
• Advanced verbal and written communication skills for interacting with internal and external stakeholders.
• Proficiency in MS Word Excel and internet applications.
• Highly detail-oriented with the ability to prioritize tasks effectively under pressure.

Education:

• Bachelors degree required.
• Industry designations such as AIC SCLA or CPCU are a plus.

Disclaimer: Please note that this job description may not cover all duties responsibilities or aspects of the role and it is subject to modification at the employers discretion.

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