Workers Compensation, Claims Specialist II

Claim Specialist II, Workers Compensation If you’re passionate about helping people protect what matters most to them at a Fortune100 company with nearly $70billion in annual sales, and you enjoy innovating and simplifying processes to deliver the best customer value, then Nationwide’s Property & Casualty team could be the place for you. At Nationwide®, “on your side” goes beyond just words; our customers and partners are at the center of everything we do, and we’re looking for associates who are passionate about delivering extraordinary care. Do you have a strong desire to provide prompt, courteous and fair service to customers? Are you a skilled investigator, negotiator and communicator? If you thrive in an environment where you can problem‑solve workers’ compensation claims while following processes that ensure fair resolution, customer satisfaction and cost management, then we want to hear from you! As a Claims Specialist, you’ll investigate and handle medical and/or loss‑of‑time workers’ compensation claims from multiple states to determine compensability, entitled benefits, average weekly wage and benefit rate according to applicable state statutes. Key Responsibilities Provides appropriate notices to policyholders and injured employees according to applicable state workers’ compensation statute and obtains appropriate forms and documentation to verify employee/employer relationship and average weekly wage. Completes and files appropriate first and second notice of injury as required by state statute and electronic data interchange reporting regulations. Employs appropriate claims management techniques and direct intervention (e.g., independent medical examinations, referral for rehabilitation, utilization review, etc.) to manage each case. Maintains contact with policyholders and injured workers and pursues return‑to‑work initiatives. Utilizes effective Telephonic Nurse Case Manager or Field Nurse Case Management services to assist with managing medical care and return‑to‑work activities. Consults with internal Claims Medical Specialist for future care needs and issues of life expectancy. Evaluates exposures, manages ongoing case reserves in alignment with best practices and negotiates settlements as appropriate. Documents significant activity and decisions in each claim via on‑line claim system. Evaluates all pertinent information and works with claimant/client to pursue the most appropriate resolution. Investigates and pursues third‑party recoveries and any applicable deductibles. May utilize Nationwide recovery unit, partner with outside counsel/trial division, or give notice of lien to plaintiff counsel handling third‑party litigation. Field assist referrals and/or outside consulting experts may be utilized to gather, obtain and secure critical information. Manages litigated claim issues in alignment with best claims practices. Obtains appropriate litigation budgets and develops power of attorney in partnership with counsel. Manages litigation expenses of Nationwide Trial Division or approved outside counsel. Manages assigned claims with little to no direction and oversight, making decisions within delegated authority as outlined in company policies. Adheres to high standards of professional conduct consistent with delivery of superior service. Submits severe incident reports, reinsurance reports and other information to home office, claims management, and underwriting. Reviews files for Medicare reporting obligations and submits appropriate Medicare query. Maintains ongoing responsibility for Medicals (ORM) and Total Payment Obligation to claimant (TPOC) reports. Is responsible for claims involving Medicare Set‑Aside at settlement, including those funded by a structured settlement. Partners with Special Investigative Unit (SIU) and Subrogation to identify fraud and subrogation opportunities. Delivers a positive customer‑service experience to all internal, external, current and prospective Nationwide customers. May periodically conduct customer/account visits to review reserves and discuss the status of significant claims. May present educational workshops to client personnel. May perform other responsibilities as assigned. Typical Skills and Experiences Education: Undergraduate studies in business administration or related field preferred and/or relevant workers’ compensation experience. License/Certification: State licensing where required; successful completion of required/applicable claims certification training/classes. Experience: Three to five years prior experience in workers’ compensation claims. Knowledge, Abilities and Skills: Advanced knowledge of insurance theory, practices and contract application. Familiarity with claims processing and best practices. Proven knowledge of insurance contracts, medical terminology, workers’ compensation and legal aspects of court procedures. Knowledge of claims systems. Excellent customer focus and proactive to meet customer needs. Analytical skills for coverage decisions, application of laws, policy exclusions and exceptions. Capability to establish repair requirements and cost estimates for extensive losses. Organizational skills to prioritize complex workloads. Leadership capabilities to train, coach, and provide feedback to less experienced associates. Excellent written and verbal communication skills. Job Conditions Overtime Eligibility: Exempt (Not Eligible). Working Conditions: Normal office environment. May require irregular hours and travel, including occasional overnight stays and catastrophe response. ADA: The above statements cover principal functions; specific circumstances may allow a different combination of duties. Credit/background check required. Benefits Medical, dental and vision coverage Life insurance Short‑term and long‑term disability coverage Paid time off: minimum of 18 days for newly hired associates, nine paid holidays, 8 hours of Lifetime PTO, 8 hours of Unity Day PTO 401(k) with company match Company‑paid pension plan Business casual attire allowance Other benefits as detailed in the benefits guide Equal Opportunity Employment Nationwide is an equal‑opportunity employer. We celebrate diversity and are committed to creating an inclusive culture where everyone feels challenged, appreciated, respected and engaged. Nationwide prohibits discrimination and harassment and affords equal employment opportunities to employees and applicants without regard to any characteristic protected by applicable law. This position could be filled within any of the lower 48 U.S. states. #J-18808-Ljbffr