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ProfileLead Workers Comp Claims Adjuster The candidate will investigate, coordinate and process 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. Promote and provide "On Your Side" customer service. Establish timely and appropriate case reserves in accordance with Best Practices and manages claims to appropriate resolution. Provide timely and accurate claims administration according to contract and/or client service plan and within applicable state laws. Complete state and other regulatory reports/forms to include EDI forms as required by each State Workers Compensation Statute or State Regulatory Rules. Assist with assignment of new claims. Employ appropriate claims management techniques and direct intervention (I.e., independent medical examinations, referral for rehabilitation, utilization review, etc.) to manage each claim. Maintain contact with policyholders and injured worker and pursues return to work initiatives. Utilize effective TNCM or Field Nurse Case Management services to assist with managing medical care and return to work activities. Consult 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. Document significant activity and decision in each claim via on-line claim system. Manage litigated claim issues in accordance with Best Claims Practices. Obtain appropriate litigation budgets and develops appropriate POA in partnership with counsel, and manages litigation expenses of Nationwide Trial Division or approved outside counsel. Evaluate all pertinent information and works in conjunction with claimant/client to pursue most appropriate claims resolution. Fully investigate 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. Open, close and adjust reserves in accordance with company practices designed to ensure reserve adequacy. Recommend Special Reserves where necessary. Maintain 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. Serve as a mentor to less experienced claims associates and assists with training/presentations as assigned by claims management. Assist with the training and development of other claims associates. Serve 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. Review files for Medicare reporting obligations and submits appropriate Medicare query,ORM and TPOC reports. Provide 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. Complete and file appropriate FROI and SROI's as required by individual State Workers Compensation Statute and EDI reporting regulations. Assist 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. Will handle claims involving MSA's at time of settlement and which may be funded by a Structured Settlement. Consult claims staff and defense counsel for discovery processes, suit file/trial strategy as related to case-specific issues. Consult claims staff and defense counsel for discovery processes, suit file/trial strategy as related to case-specific issues. Deliver a positive On-Your-Side customer service experience to all internal, external, current and prospective Nationwide customers. May periodically conduct customer/account visits to review reserves and discuss status of significant claims. May also present educational workshops to client personnel. May serve as unit leader when the Manager is out of office.
Qualification and Experience
Undergraduate degree or equivalent experience preferred. Advanced degrees in law or related discipline preferred. Successful completion of required claims certification schools/courses. Professional development such as IIA or CPCU preferred. State licensing where required. 5+ years of work experience in workers compensation claims required. Successful completion of formal claims training program per business unit standards required. Detailed knowledge of medical, legal and workers compensation terminology, state regulations to include EDI reporting obligations, claims processes, best practices, and customer relationship management required. Advanced knowledge of insurance theory and practices, insurance contracts and their application required. Familiarity with claims processing and claims best practices and procedures preferred. Proven knowledge of insurance contracts, medical terminology, workers compensation, and the legal aspects of court procedures affecting legal liability for all lines of insurance required. Knowledge of claims systems required. Command of all skills necessary for verbal and written communication required. Ability: to operate personal computer to input and retrieve data via on-line claims administration system; to set work priorities and to plan and executive work within deadlines; to analyze claim information and statistical data; to perform mathematical calculations necessary to set reserves; to analyze and interpret medical reports; to negotiate effective resolution of claims issues, including settlements required.
Job ID: 47222