This Lead Workers' Compensation Claims Spec III position will be staffed in our Lincoln, NE office. Must have a minimum of 5 years of previous/current Workers' Compensation claims handling experience. Would consider those with a combination of transferable skills/experience (Legal and/or Medical) with Workers' Compensation claims handling.
JOB SUMMARY: Investigates, coordinates and processes the most complex medical and indemnity workers compensation claims involving multiple states to determine compensability, entitled benefits, average weekly wage and benefit rate, in accordance with applicable State Workers Compensation Statute. Promotes and provides "On Your Side" customer service. Establish timely and appropriate case reserves in accordance with Best Practices and manages claims to appropriate resolution. Provides timely and accurate claims administration according to contract and/or client service plan and within applicable state laws.
RELATIONSHIP: Reports to Supervisor/Manager
1. Completes state and other regulatory reports/forms to include EDI forms as required by each State Workers Compensation Statute or State Regulatory Rules.
2. Assist with assignment of new claims.
3. Employs appropriate claims management techniques and direct 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 TNCM or Field Nurse Case Management services to assist with managing medical care and return to work activities. Consults with internal CMS for future care needs and issues of LE. Evaluates exposures, manages ongoing case reserves in accordance with Best Practices and negotiates settlements as appropriate. Documents significant activity and decision in each claim via on-line claim system.
4. Manages litigated claim issues in accordance with Best Claims Practices. Obtains appropriate litigation budgets and develops appropriate POA in partnership with counsel, and manages litigation expenses of Nationwide Trial Division or approved outside counsel.
5. Evaluates all pertinent information and works in conjunction with claimant/client to pursue most appropriate claims resolution.
6. Fully 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.
7. Opens, closes and adjusts reserves in accordance with company practices designed to ensure reserve adequacy. Recommends Special Reserves where necessary.
8. 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.
9. Serves as a mentor to less experienced claims associates and assists with training/presentations as assigned by claims management.
10. Assists with the training and development of other claims associates.
11. Serves as 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.
12. Reviews files for Medicare reporting obligations and submits appropriate Medicare query,ORM and TPOC reports.
13. Provides appropriate notices to policyholders and injured employee on complex claims in accordance with applicable state Workers Compensation statute, and obtains appropriate forms and documentation to verify employee/employer relationship and average weekly wage. Completes and files appropriate FROI and SROI's as required by individual State Workers Compensation Statute and EDI reporting regulations.
14. 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.
15. Will handle claims involving MSA's at time of settlement and which may be funded by a Structured Settlement.
16. Consults claims staff and defense counsel for discovery processes, suit file/trial strategy as related to case-specific issues.
17. Consults claims staff and defense counsel for discovery processes, suit file/trial strategy as related to case-specific issues.
18. Delivers a positive On-Your-Side customer service experience to all internal, external, current and prospective Nationwide customers.
19. May periodically conduct customer/account visits to review reserves and discuss status of significant claims. May also present educational workshops to client personnel.
20. May serve as unit leader when Manager is out of office.
21. Will serve as a role model and mentor to less experienced Associates.
22. Other duties as assigned.
Education: Undergraduate degree or equivalent experience preferred. Advanced degrees in law or related discipline desirable.
Licenses/Designations: 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: 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 compensaiton, and the legal aspects of court procedures affecting legal liability for all lines of insurance. Knowledge of claims systems.
Skills/Competencies: 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 consitent with a positive Associate engagement, and actions consistent with the Nationwide Values. Able to present complex information in a manner easlily understandable to other business units or Associates with less experience. Can handle multiple project assignments in addition too and simultaneous to claim handling duties. Posesses ability to teach, train and motivate others.
Values: Regularly and consistently demonstrates the Nationwide Values and Guiding Behaviors.
Staffing Exceptions to the above Minimum Job Requirements must be approved by: Business Unit Executive and Human Resources.
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.
Credit/Background Check: Due to the fiduciary accountability within this job, a valid credit check and/or background check will be required as part of the selection process.
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.
Nationwide Mutual Insurance Company - 17 months ago