NJM’s Workers’ Compensation Claims Team is seeking a Regional Claims Specialist (I/II/Sr.). This is a full-time position and offers a hybrid schedule after training.
The Regional Claims Specialist will be responsible for contacting all parties involved in the claim, gathering, and securing all necessary information to effectively evaluate the claim, and outlining and recommending an action plan to manage the claim. The Regional Claim Specialist will work with and communicate to all internal and external stakeholders, including: NJM policyholders, injured workers, medical providers, the NJM Medical Services Administration Department, the NJM Special Investigation Unit, WC Legal Staff, and other departments within NJM, as well as outside defense counsel and vendors.
This role is based in our NJM’s West Trenton office location.
Hours: Monday to Friday 8:00AM- 4:15PM (Hours can very depending on start time).
Responsibilities:
Execute on strategic and operational goals and objectives of the WCC department and company business goals, guidelines, and programs
Recommend process improvement where applicable to best improve the department efficiency, work product, and service commitment to interested parties
Manage litigated claims through with proactive execution of action plans to resolve claim issues to move cases toward closure and reduce aged inventory
Ensure quality management of claims in accordance with claims best practices and company guidelines, and timely, accurate documentation of claim activity
Provide a high level of customer service that promotes injured worker advocacy-based principles to maximize return to work motivation and improve outcomes for all parties.
Determine compensability and coverage issues that have been placed in litigation by gathering medical and factual evidence
Administer the delivery of timely, appropriate, and accurate indemnity and medical benefits
Evaluate the claim for potential fraud indicators and escalates the file to SIU, as appropriate.
Recognize and investigate subrogation opportunity for recovery of third-party funds
Initiate and provide excellent communication with all stakeholders (injured workers, providers, attorneys, brokers, clients, etc.) professionally and proactively with a customer-centric approach
Apply critical thinking skills to evaluate and mitigate exposures, and establish and implement a proactive strategic plan of action
Assign and refer claim petitions to Counsel, and work to resolve the claim within given authority
Promptly manage and resolve issues on litigated cases, inclusive of evaluating claim exposure, negotiating, and resolving claims
Build rapport with the policyholder, conduct on-site investigations when necessary, and educate the policyholder on NJM legal procedures, policies, and claim practices
Prepare for Claim Reviews; attend and participate as needed with the Claims Team and Supervisor
Participate in in-house and outside training programs to keep current on relevant issues/topics
Demonstrate a commitment to NJM’s Code of Business Conduct and Ethics, and apply knowledge of compliance policies and procedures, standards, and laws applicable to job responsibilities in the performance of work
Required Qualifications and Experience:
Level I- 1-3 years’ experience as a Workers' Comp Claim Representative, or comparable knowledge and experience with various aspects of claims handling and/or process including strong knowledge of WC Law, medical terminology, and utilization of an automatic claims processing system.
Level II- 3-5 years’ experience as a Workers' Comp Claim Representative, or comparable knowledge and experience with various aspects of claims handling and/or process including strong knowledge of WC Law, medical terminology, and utilization of an automatic claims processing system.
Sr Level – 5+ years’ experience as a Workers' Comp Claim Representative, or comparable knowledge and experience with various aspects of claims handling and/or process including advanced knowledge of WC Law, medical terminology, and utilization of an automatic claims processing system.
Knowledge of WC regulations and jurisdiction(s) to be able to formulate a Plan of Action to bring claims to resolution
Knowledge of and experience working Work with liens and Medicare Set-Asides to secure full and final settlements
Customer service oriented with strong written and oral communication skills
Strong interpersonal skills with ability to work both in a team and independently
Demonstrated organizational skills, and use of sound decision-making capabilities
Working knowledge utilizing an automated claim processing system and the Microsoft Office suite of tools (Word, Excel)
Ability to travel for business purposes, approximately less than 10%
Preferred:
Multi-state experience and/or licensing (including NJ, MD, CT, DE, PA and/or NY)
Associate’s or Bachelor’s degree
AIC/CPCU Designations
Salary: The position can be filled at a I, II, or Sr. level. Salary is commensurate with experience and credentials.
Level I- $57K+ annually based on experience and credentials
Level II - $65K+ annually based on experience and credentials
Sr Level - $79K+ annually based on experience and credentials
Benefits Offered:
Medical Insurance (Blue Cross Blue Shield)
Dental Insurance (Delta Dental)
Vision (Delta Vision/ VSP)
Flexible Spending Account
Discounts on NJM auto insurance
Tuition reimbursement
Life insurance
Plus, additional company discounts for items like travel, service, car rental and more!
Legal Disclaimer: NJM is proud to be an equal opportunity employer. We are committed to attracting, retaining and promoting a diverse and inclusive workforce that is fully representative of the diversity that exists in the communities in which we do business.
