JOB SUMMARY: Investigates medical and/or loss of time workers compensation claims with limited exposures 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 manage claim to appropriate closure. Provides timely and accurate claims administration according to contract and/or client service plan and within applicable state laws.
RELATIONSHIP: Reports to Supervisor/Manager
DIRECT REPORTS: None
1. Provides appropriate notices to policyholders and injured employee 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.
2. 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.
3. Evaluates all pertinent information and works in conjunction with claimant/client to pursue most appropriate claims resolution.
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. Promptly and effectively handles to conclusion all assigned claims with moderate direction and oversight. Makes decisions within delegated authority as outlined in company policies and procedures. Adheres to high standards of professional conduct consistent with the delivery of superior service.
6. Initiates and conducts follow-ups via proficient use of claims systems and related business systems
7. 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.
8. Partners with SIU and Subrogation to identify fraud and subrogation opportunities.
9. Maintains and develops current knowledge of: assigned insurance lines; court decisions which may impact the claims function; current guidelines in the claims function; and policy changes and modifications. This may require attendance at various seminars or training sessions.
10. Completes state and other regulatory reports/forms to include EDI forms as required by each State Workers Compensation Statute or State Regulatory Rules.
11. Reviews files for Medicare reporting obligations and submits appropriate Medicare query, ORM and TPOC reports. May handle claims involving MSA's at time of settlement.
12. Assists or prepares files for suit, trial, or subrogation. (Property/MD/Casualty)
13. Delivers a positive On-Your-Side customer service experience to all internal, external, current and prospective Nationwide customers.
14. May periodically conduct customer/account visits to review reserves and discuss status of significant claims. May also present educational workshops to client personnel.
15. Initiates and conducts follow-ups via proficient use of claims systems and related business systems.
16. Other duties as assigned.
Education: Undergraduate degree or equivalent experience preferred.
Licenses/Designations: State licensing where required. Successful completion of required claims certification schools/classes.
Experience: One to three years experience in workers compensation claims.
Knowledge: General 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. Analytical skills necessary to make decisions/resolve conflicts such as application of coverage's to submitted claims, application of laws of jurisdiction to investigation facts, application of policy exclusions and exceptions, and direct repaid shop claims management. Ability to work in a fast paced and team based environment. Organizational skills to effectively prioritize and manage increased workloads. Demonstrated proficiency of written/verbal communication skills for contact and/or negotiations with policyholders, claimants, repair persons, attorneys, agents, and the public in general. Ability to efficiently operate personal computer and software for claims-related and other business applications.
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 accountabilities 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 - 16 months ago