Claims Specialist

Job Title: Claims Specialist

Department: Claims

Reports To: Claims Manager

Position Summary:

This position provides expert claim handling services in the areas of coverage, compensability, investigation, evaluation, negotiation, litigation management and resolution of serious and complex workers' compensation insurance claims under applicable law, corporate policy and best practice. Quality claim handling expertise, Service Excellence and indemnity and expense management will also be provided by the position. The claims specialist will also be an expert technical resource to other claims professionals, business partners, policyholders and stakeholders.

Essential Functions:

• Evaluate, analyze and determine compensability, causation, offsets and exposures of serious and complex workers compensation insurance claims in accordance with applicable law, corporate policy, best practice and prescribed authorities
• Verify claim information including but not limited to: documentation of the claim history; taking recorded statements from workers and witnesses, identify subrogation opportunities, coordination of medical care.
• Document all activities in the claim management system. Responsible for outside legal counsel assignments, RTW strategies with policyholders, implement medical case management strategies with nurse case managers and all other expert assignments.
• Upon determination of compensability: Set and monitor reserves according to company policies and the worker's injury, issue benefit checks in accordance to statutory requirements, and demonstrate proficiency in the application of state statutes, related case law and to interpret and comply with company claims standards, policies and procedures. Must have above-average knowledge, understanding and ability to apply case law to claim handling practices.
• Ensure the timely and accurate statutory/benefit payments within the established time frames and guidelines.
• Prepare and participate in mediation conferences and other authorized legal or regulatory proceedings before the regulatory agencies and courts of law.
• Maintain a diary on all open claims. Document all relevant information to provide a clear history of events and a proper audit trail. Set review dates based on claim complexity or standard review criteria.
• Assess and report claims litigation for significant financial exposure, case law precedent or reputation risk.
• Identify and recommend claims with potential for full and final settlement and negotiate and/or coordinate with authorized outside legal counsel in full and final settlements.
• Analyze assigned claims to identify trends and opportunities for improvement of policies, procedures and controls, and prepare related reports.
• Mentor junior adjusters and provide support to Claims Managers as directed.
• Detect and report reasonable suspicions of insurance fraud by claimants, medical or legal providers, policyholders or other individuals related to claims.
• Maintain claim records in compliance with applicable law, corporate policies and retention schedules.

Requirements

Job Qualifications:

Education:

Bachelor's Degree from an accredited college or university.

Experience:

5+ years of serious workers' compensation claims experience. 10+ claims handling experience.


Specialized Knowledge, Licenses, etc.: Demonstrated proficiency in:

• Related professional certifications preferred
• State required adjuster's license

Values and Mission:

Adhere to values and mission by demonstrating Service Excellence, Trust, Ownership, One team and Boldness in thought and action.

Positive Attitude:

Develops and maintains positive working relationships with team members, customers, co-workers and management by demonstrating effective communication and collaborative skills.

Working Conditions:

• NEW MEXICO MUTUAL maintains general office conditions with light physical demands, with occasional lifting.
• Employees of NEW MEXICO MUTUAL adhere to all safety rules and regulations including building security.
• Employees participate in ensuring safe and efficient operating conditions that safeguard employees and facilities.
• NEW MEXICO MUTUAL maintains a drug free environment; drug testing prior to employment as well as upon a work related accident.
• Exposure to VDT screens.