Primary Responsibilities:
- Independently investigate, evaluate, negotiate, manage, and resolve complex workers' compensation claims in a good faith manner..
- Serve as a subject matter expert for workers' compensation regulations, claim handling best practices, and emerging industry trends.
- Analyze medical, legal, vocational, and financial information to determine reserves, compensability, liability exposure, and settlement opportunities.
- Provides recommendations to management regarding litigation, settlement authority, and risk mitigation.
- Partner with legal counsel, medical providers, third-party administrators, brokers, and regulatory agencies to facilitate claim resolution.
- Perform quality reviews and audits of claim files to ensure consistency, compliance, and adherence to organizational standards.
- Act as a mentor and resource for Claims Analysts I and II, providing coaching, knowledge transfer, and claims guidance.
- Lead special projects, process improvement initiatives, and cross-functional efforts related to workers' compensation operations.
- Maintain accurate documentation and timely claim handling activities in accordance with company standards and jurisdictional requirements.
- Demonstrates advanced proficiency in leveraging emerging technologies, automation tools, and AI resources to optimize claim handling operations, drive process improvements, and elevate customer service outcomes.
- Serves as a resource to others by promoting technology adoption, identifying innovative solutions, and influencing best practices that improve efficiency, accuracy, and organizational performance.
Knowledge and Requirements:
- High School Diploma or GED required. Bachelor's degree in Business, Risk Management, Insurance, Human Resources, or related field preferred.
- Minimum 5+ years of workers' compensation claims handling experience.
- Demonstrated experience handling complex, litigated, and high-exposure workers' compensation claims.
- Advanced knowledge of workers' compensation laws, regulations, and claims practices across multiple jurisdictions.
- Proven ability to independently manage large claim inventories and complex investigations.
- Strong analytical, negotiation, and decision-making skills.
- Excellent written and verbal communication skills.
- Advanced proficiency with claims management systems and Microsoft Office applications.
- Ability to exercise sound judgment and discretion in sensitive situations.
- Travel as needed to customer locations, hearings, mediations, or claim-related meetings.
- Associate in Claims (AIC), CPCU, ARM, WCP, or other industry designation preferred.
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