Workers Compensation Claims Specialist Senior

NJM’s WC Claims Department is seeking an experienced Claims Specialist, Sr. who lives in Western or Central PA to provide on-site service to our policyholders and agents in that area.This is a 100% remote position which includes virtual claims handling for customers in any area of PA and possibly MD, DE or CT as needed.

At NJM, our WC Claims Department empowers our employees to focus on delivering guidance and empathy to our customers.  As a department driven by service and customer advocacy, we are committed to providing transparent, empathetic support and collaborative engagement during the life of a claim. The WC Claims Department takes pride in being a key component in the growth and success of our policyholders’ business operations.

To meet these expectations, WC Claims Specialists are supported by a dedicated call center who can field calls for them and other specialized units who are responsible for setting reserves, making permanency payments, and following through on subrogation so they can dedicate the time needed to manage claims. Many of our staff are long-tenured with a focus on building relationships, not only with our customers, but with each other providing a positive and nurturing work environment.

Hours:

Monday to Friday 8:00AM- 4:15PM (Hours can vary depending on start time).

Training is required at the NJM- West Trenton office.

Responsibilities:

• Ensure quality management of claims in accordance with claims best practices and company guidelines, and timely, accurate documentation of claim activity

• Provide a high level of customer service that promotes injured worker advocacy-based principles to improve outcomes for all parties 

• Determine compensability and coverage issues by gathering medical and factual evidence

• Administer the delivery of timely, appropriate, and accurate benefits

• Evaluate the claim for potential fraud indicators and escalate the claim to SIU, as appropriate

• Recognize and investigate subrogation opportunity and refer to NJM subrogation staff for recovery of third-party funds

• Initiate and provide excellent communication with all stakeholders (injured workers, medical providers, attorneys, policyholders, agents, etc.) professionally and proactively with a customer-centric approach

• Apply critical thinking skills to evaluate and mitigate exposures, and establish and implement a proactive strategic plan of action

• Assign and refer claim petitions to Counsel, and work to resolve the claim within given authority

• Build rapport with policyholders and agents, conduct on-site investigations when necessary, and educate policyholders and agents on NJM procedures, policies, and claim practices

• Prepare and attend Claim Reviews at policyholder or agent locations in Western and/or Central PA or virtually for further locations.

• Serve as a liaison between policyholders/agents and various departments in NJM.

• Represent WC Claim in on-site capabilities meetings to onboard new policyholders in Western and/or Central PA.

• Participate in training programs to keep current on relevant issues/topics

• Recommend process improvement where applicable to best improve the department efficiency, work product, and service commitment to interested parties

• Demonstrate a commitment to NJM’s Code of Business Conduct and Ethics, and apply knowledge of compliance policies and procedures, standards, and laws applicable to job responsibilities in the performance of work

Required Qualifications and Experience:

• 5+ years’ experience as a Workers' Comp Claim Representative, or comparable knowledge and experience with various aspects of claims handling and/or process including advanced knowledge of medical terminology and WC regulations for PA, MD and/or DE claims.

• Knowledge of and/or experience working with liens and Medicare Set-Asides to secure full and final settlements

• Customer service oriented with strong written and oral communication skills

• Strong interpersonal skills with ability to work both in a team and independently

• Demonstrated organizational skills, and use of sound decision-making capabilities

• Working knowledge utilizing an automated claim processing system and Microsoft Office tools including Word and Outlook

• Licensed in DE and/or CT to adjust WC claims or have the ability to obtain these licenses within 90 days.

• Ability to travel for business purposes, approximately 2 – 3 days a week meeting with policyholders and/or agents

Preferred:

• Associate or bachelor’s degree

• AIC/CPCU or other applicable insurance designations

• Experience using Guidewire Claim Center, OnBase and additional Microsoft Office tools including Teams, Excel and PowerPoint

• Knowledge and experience in claims handling for other commercial line products in various states including PA, MD and/or DE.

Salary:

• Sr Level starting rate is $79,129.05+ annually based on experience and credentials

Compensation: Salary is commensurate with experience and credentials.

Pay Range: $79,129-$91,834