Complex Claims Specialist, Senior Job Listing at NJM Insurance Group in Trenton, NJ (Job ID R2007738)

Description

The overall responsibility of this position is to consistently execute on the Company's mission, vision, and values, leading customer service approach, and claims business model to provide best outcomes on complex/high severity claims. The Complex Claims Specialist, Senior will be responsible for contacting all parties involved in the claim, gathering, and securing all necessary information to effectively evaluate the claim, and implement an action plan to manage the claim.

The Complex Claims Specialist, Sr will work with and communicate to NJM policyholders, injured workers, medical providers, the NJM Medical Services Administration Department, Special Investigation Unit, WC Legal Staff, other departments within NJM, and vendors as needed. This is a senior level position in the Complex Claims track that will require minimal supervision and guidance to accomplish the goals and objectives of the role.

Essential Duties and Responsibilities:

• 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.

• Will prepare for, attend, participate with the Supervisor at Claim Reviews with customers and brokers.

Required Qualifications:

• 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

Preferred Qualifications:

• Multi-state experience and/or licensing (including NJ, MD, CT, DE, PA and/or NY)

• Associate's or Bachelor's degree

• AIC/CPCU Designations

Compensation: Salary is commensurate with experience and credentials.

Eligible full-time employees receive a competitive Total Rewards package, including but not limited to a 401(k) with employer match up to 8% and additional service-based contributions, Health, Dental, and Vision insurance, Life and Disability coverage, generous PTO, Paid Sick Leave, and paid parental leave in addition to state-mandated leave. Employees may also be eligible for discretionary bonuses.

Legal Disclaimer: NJM is proud to be an equal opportunity employer. We are committed to attracting, retaining and promoting a diverse and inclusive workforce that is fully representative of the diversity that exists in the communities in which we do business.