Lost Time Claims Specialist, Workers' Compensation

Job Overview Salary range: $55,132.00 - $110,642.00 annually + bonus + benefits. Pay Type: Salary. The above represents the full salary range for this job requisition. The salary and job title will be determined based on location, education, experience and other factors, and will fall within the stated range. Your recruiter can provide further details during the hiring process. We consider candidates residing in any of our payroll‑approved states. This role manages Workers’ Compensation Lost Time and Medical Only claims in multiple jurisdictions, including Virginia and New England territory. Ideal candidates will have experience managing Workers’ Comp claims in Massachusetts, Rhode Island or New Hampshire. The position reports to the Director, Workers’ Compensation Claims. Key Responsibilities Evaluates and establishes an action plan to manage medical and indemnity benefits associated with injury and occupational disease claims to the most cost‑effective conclusion. Decides claim outcomes using sound judgment by applying established policy, procedures, regulations and guidelines. Gathers facts by conducting interviews with all involved parties and considers all elements of the claim before issuing a decision. Takes recorded statements when necessary. Determines eligibility of indemnity and medical benefits once salary information and medical treatment plans have been secured and processed within the designated authority levels. Utilizes proactive reserving behaviors to ensure adequate case reserves that reflect the probable ultimate outcome based on the current known circumstances throughout the life of the claim. Actively identifies and develops the investigation and pursuit of subrogation recoveries when possible. Consults with assigned claim director, return‑to‑work specialists, nurse case managers, internal/external medical and legal professionals on current and/or recommended treatment, litigation or rehabilitation plans to ensure claims outcomes are achievable and appropriate. Works collaboratively with the injured worker, employer, outside counsel, and health and rehabilitation professionals to manage the claims costs and promote quality medical care. Works collaboratively with the injured worker, employer, assigned return‑to‑work specialist and medical providers to facilitate the injured worker’s safe and timely return to work. Manages claims litigation, including expenses, by collaborating and providing direction to panel counsel throughout the life of the claim. Analyzes reports from external resources such as physicians, attorneys and/or vocational rehabilitation experts to evaluate and adjust claim strategies as needed. Evaluates and negotiates claim settlements using human relation skills and technical knowledge to achieve the best possible outcome. Presents and summarizes claim details at internal team staffing, participates in discussions and provides guidance as needed. Consults with assigned claim director if the loss becomes significantly complex or presents significantly increasing financial exposure. Follows established claims best practices related to medical management, litigation, fraud/abuse and recovery. Effectively and independently uses available resources to prioritize, organize and complete work in a timely manner to meet jurisdictional requirements, timeframes and internal metrics. Develops presentations for special projects such as internal/external meetings and conferences as needed. Along with the claim director, regional vice president and other claims staff, participates in claim reviews, onboardings, etc. for policyholders and agents. Proactively collaborates with policyholders to ensure alignment of objectives and foster continuous improvement. Other Functions Nonessential function: other duties as assigned. Qualifications and Skills Bachelor’s Degree from an accredited college or university (preferred). Three years of experience in the field of workers’ compensation insurance (required). Ability to manage claims through the litigation process. Internal candidates must demonstrate knowledge of Encova Best Practices guidelines and meet quality standards. One valid workers’ compensation adjuster license is strongly preferred (must be eligible to obtain additional licenses as required). Must pass the claims adjuster license exam(s) within 90 days of being hired. Preference may be shown to candidates with multiple state claims management experience. Experience in workers’ compensation claims practices and laws, court procedures, precedents and state statutes. Ability to use logic and sound reasoning to identify alternative solutions for problem‑solving. Strong written and verbal communication skills. Strong analytical skills. Ability to multitask and manage time effectively and productively. Work effectively independently as well as in a team environment. Develop and maintain strong, effective internal and external relationships. Work effectively in a paperless environment. Skilled in the use of laptops, claims management systems and other typical business‑related programs such as Microsoft Office suite. Benefits Health, dental & vision insurance. Company‑provided life and income protection plans. Eligibility to participate in a company incentive bonus program. 401(k) retirement plan – 100% company match up to 7% of annual salary. Paid time off, paid holidays and floating holidays. Flexible work arrangements – hybrid and remote depending on the role. This position has been evaluated in accordance with the Americans with Disabilities Act. Encova Insurance makes every effort to reasonably accommodate disabilities to permit performance of the essential functions and candidates who need such accommodation are encouraged to seek it. Encova Insurance is an EOE/E‑Verify employer. #J-18808-Ljbffr Encova Mutual Insurance Group.