MEMIC

Claims Specialist

• Communicates with insureds, injured workers, agents, brokers, witnesses, attorneys, loss prevention, and underwriters to obtain and relate necessary information to determine coverage/compensability, facts of loss, and degree of liability/exposure.
• Maintains contact throughout the life of the file as needed.
• Administers the delivery of timely, appropriate and accurate indemnity and medical benefits.
• Evaluates claim exposure, negotiate and resolve claims.
• Works closely with defense counsel on litigated cases and attend mediation, arbitration, and hearings, as necessary.
• Develops litigation plan with defense counsel and tracks adherence to plan in order to control legal expenses and assure effective resolution.
• Works closely with insureds and employees making visitations and presentations as needed to facilitate partnership approach to claims handling.
• Maintains quality claim files in accordance with appropriate best practices, and other company procedures.
• Implements Managed Care strategies, coordinate rehabilitation or medical management, process bills, review all mail through Image Right, and monitor progress as appropriate.
• Interacts with State and Federal Boards and Commissions, while establishing and maintaining proper reserves, as appropriate.
• Serves as a mentor and helps prepare/train the less experienced Claim Department representatives.
• Keeps up-to-date on State laws and Company procedures relating to various claims; educates injured worker and/or insured on same.
• Prepares and presents files for Agent/Broker Reviews and Insured File Review.
• Understands medical terminology and standard medical procedures as they pertain to worker’s compensation, U.S. Longshoreman’s and Jones Act claims.
• Participates in in-house and outside training programs to keep up-to-date on relevant issues/topics.
• Maintains a working knowledge of all computer systems currently in use.
• Travels throughout States as required to handle claims inventory assigned.
• Continues education in claims through Associate in Claims or Claims Law (AEI) courses.

Claim Specialist I/II, Pennsylvania WC Claims

• Communicates with insureds, injured workers, agents, brokers, witnesses, attorneys, loss prevention, and underwriters to obtain and relate necessary information to determine coverage/compensability, facts of loss, and degree of liability/exposure.
• Administers the delivery of timely, appropriate and accurate indemnity and medical benefits.
• Evaluates claim exposure, negotiate and resolve claims. Works closely with defense counsel on litigated cases and attend mediation, arbitration, and hearings, as necessary. Develops litigation plan with defense counsel and tracks adherence to plan in order to control legal expenses and assure effective resolution.
• Works closely with insureds and employees making visitations and presentations as needed to facilitate partnership approach to claims handling.
• Maintains quality claim files in accordance with appropriate best practices, and other company procedures.
• Implements Managed Care strategies, coordinate rehabilitation or medical management, process bills, review all mail through Image Right, and monitor progress as appropriate.
• Interacts with State and Federal Boards and Commissions, while establishing and maintaining proper reserves, as appropriate.
• Serves as a mentor and helps prepare/train the less experienced Claim Department representatives.
• Keeps up-to-date on State laws and Company procedures relating to various claims; educates injured worker and/or insured on same.
• Prepares and presents files for Agent/Broker Reviews and Insured File Review.
• Understands medical terminology and standard medical procedures as they pertain to worker’s compensation, U.S. Longshoreman’s and Jones Act claims.
• Participates in in-house and outside training programs to keep up-to-date on relevant issues/topics.
• Maintains a working knowledge of all computer systems currently in use.
• Travels throughout States as required to handle claims inventory assigned.

Claim Specialist I – IV, New York WC Claims

Procurement

• Design and execute medical management strategies that support early intervention and injury triage, ensure appropriate utilization of medical services, and promote timely return-to-work outcomes.
• Establish clear productivity, quality, and outcome-based performance expectations tied to claim outcomes, and ensure consistent clinical decision-making aligned with evidence-based guidelines and jurisdictional requirements.
• Manage and develop Managed Care Services team. Foster the C.A.R.E model philosophy throughout the department. Foster strong collaboration between Managed Care Services teams and Claims Adjusters to drive optimal claim resolution.
• Oversee all external medical management vendors, including pharmacy management vendors, ancillary management vendors, utilization review vendors, case management vendors, IME and peer review providers, and medical bill review and PPO/network partners.
• Develop and manage vendor strategy, including selection, onboarding, and ongoing optimization, while establishing and enforcing service level agreements (SLAs) and key performance indicators (KPIs) such as turnaround times, clinical quality and accuracy, return-to-work outcomes, and cost savings and bill reductions.
• Conduct regular vendor scorecards, audits, and business reviews, and identify opportunities to consolidate vendors or expand capabilities to drive efficiency and quality improvement.
• Partner closely with Claims leadership to align medical management interventions with each stage of the claim lifecycle, provide clinical support on complex and high-exposure claims, and improve adjuster adoption of medical management tools and resources.
• Develop workflows that integrate medical management into claims systems and processes, and serve as a clinical escalation point for challenging or litigated claims.
• Drive initiatives to reduce medical spend while improving outcomes, including reducing unnecessary or prolonged treatment, avoiding opioid overutilization, and improving network utilization.
• Implement standardized workflows across internal and vendor operations. Identify opportunities for automation and technology enablement (e.g., workflow tools, predictive analytics). Lead continuous improvement initiatives focused on efficiency, quality, and consistency.
• Manage departmental budget, including internal staffing and vendor spend. Evaluate ROI of medical management programs and vendor relationships. Support actuarial and finance teams with medical cost forecasting insights.
• Ensure all activities remain aligned with state-specific Workers’ Compensation statutes and treatment guidelines, such as ODG and ACOEM.
• Monitor and report on key metrics such as medical severity trends, lost time duration, return-to-work rates, and cost per claim, and leverage analytics to identify trends, outliers, and opportunities for targeted intervention.

Director – Managed Care Services, Vendor Management

General

• Communicates with insureds, injured workers, agents, brokers, witnesses, attorneys, loss prevention, and underwriters to obtain and relate necessary information to determine coverage/compensability, facts of loss, and degree of liability/exposure.
• Administers the delivery of timely, appropriate and accurate indemnity and medical benefits.
• Evaluates claim exposure, negotiate and resolve claims. Works closely with defense counsel on litigated cases and attend mediation, arbitration, and hearings, as necessary. Develops litigation plan with defense counsel and tracks adherence to plan in order to control legal expenses and assure effective resolution.
• Works closely with insureds and employees making visitations and presentations as needed to facilitate partnership approach to claims handling.
• Maintains quality claim files in accordance with appropriate best practices, and other company procedures.
• Implements Managed Care strategies, coordinate rehabilitation or medical management, process bills, review all mail through Image Right, and monitor progress as appropriate.
• Interacts with State and Federal Boards and Commissions, while establishing and maintaining proper reserves, as appropriate.
• Serves as a mentor and helps prepare/train the less experienced Claim Department representatives.
• Keeps up-to-date on State laws and Company procedures relating to various claims; educates injured worker and/or insured on same.
• Prepares and presents files for Agent/Broker Reviews and Insured File Review.
• Understands medical terminology and standard medical procedures as they pertain to worker’s compensation, U.S. Longshoreman’s and Jones Act claims.
• Participates in in-house and outside training programs to keep up-to-date on relevant issues/topics.
• Maintains a working knowledge of all computer systems currently in use.
• Travels throughout States as required to handle claims inventory assigned.
• Continues education in claims through Associate in Claims or Claims Law (AEI) courses.

Claim Specialist I/II, Pennsylvania WC Claims

Claim Specialist I – IV, New York WC Claims

Director – Managed Care Services, Vendor Management

Claim Specialist II – III