Senior Complex Claims Specialist – Workers' Compensation
NJM Insurance Group
full-time
Posted on:
Location Type: Office
Location: Trenton • New Jersey • United States
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Salary
💰 $81,124 - $94,141 per year
Job Level
About the role
- Review, investigate, and analyze the loss event, the injury, and relevant information on all assigned claims to make a compensability decision and plan a course of action.
- Initiate and provide excellent communication with all stakeholders during the course of the claim.
- Send all appropriate documentation, including but not limited to, medical release form and wage statement at the onset of the claim process.
- Assist as needed in setting reserves.
- Manage all assigned high severity claims, including aged claims and catastrophic (CAT) losses that generate significant medical costs each year.
- Authorize quality, cost effective medical care within state statutory, regulatory, and legal guidelines, while seeking MMI threshold to mitigate future exposures.
- Early coordination with other NJM resources, including but not limited to: WC Medical Services Administration, WC Sales, WC Underwriting, WC SIU, WC Legal to provide a collective and strategic action plan.
- Authorize and issue indemnity payments and evaluate the appropriateness of making a voluntary offer of partial permanent disability.
- Document all actions taken throughout the course of the claim, adhering to each department's guidelines.
- Ensure proper data integrity to support the reporting of accurate claim data to internal and external entities.
- Effectively manage claims, build rapport and educate the policyholder, including large, assigned accounts on NJM procedures, policies and claim practices to achieve customer retention that drives to NJM goals of profit and growth.
- Frequently mentor and assist in training for developmental purposes of staff.
- Partners with the Supervisor, Sales, MCS or others in preparing for and conducting successful meetings with clients and brokers demonstrating the NJM value proposition.
- Handles all interactions with stakeholders (injured workers, providers, attorneys, brokers, clients) professionally and proactively with customer-centric approach.
Requirements
- 5-8 years’ work experience as a Workers' Comp Claim Representative, or comparable insurance knowledge and experience with various aspects of Workers' Comp claims handling and process
- Must demonstrate sound knowledge of medical terminology and applicable case law
- Customer service oriented with strong written and oral communication skills with ability to work both in a team setting and independently
- Demonstrated organizational skills aimed at bringing files to timely resolution and best outcome
- Critical thinking skills that demonstrate analysis/judgment and sound decision making with focus on attention to details
- 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%
- High school diploma or GED equivalent
Benefits
- 401(k) with employer match up to 8%
- Additional service-based contributions
- Health, Dental, and Vision insurance
- Life and Disability coverage
- Generous PTO
- Paid Sick Leave
- Paid parental leave in addition to state-mandated leave
- Discretionary bonuses
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
Workers' Comp claims handlingmedical terminologycase lawclaims analysisdecision makingdata integrityindemnity paymentsreserve settingcatastrophic lossescustomer retention
Soft Skills
communication skillscustomer service orientationorganizational skillscritical thinkingattention to detailteamworkindependencementoringrelationship buildingproactive approach
Certifications
high school diplomaGED