Senior Workers Compensation Specialist I

SUMMARY

The Senior Workers' Compensation Specialist I is responsible for managing low level and escalated workers' compensation claims and serves as a senior technical resource within the Workers' Compensation department.


This role builds upon the early-claims ownership by taking ownership of claims that extend beyond the initial lifecycle or present increased complexity, including prolonged medical treatment, lost-time exposure, or elevated risk factors.

PRIMARY FUNCTIONS

Low Level medical Claims Ownership & Management
• Own and manage medical workers' compensation claims, including those extending beyond 90 days or involving increased exposure
• Monitor claim progression and make day-to-day claim handling decisions based on medical status, return-to-work potential, and risk factors
• Identify trends, red flags, and escalation triggers that may impact claim duration or cost
• Ensure appropriate claim strategy is executed in alignment with internal standards and external partners

Claim Strategy & Escalation Oversight
• Review escalated claims from the Workers' Compensation Specialist II and assume ownership of ongoing management
• Determine appropriate next steps for complex claims, including medical management, return-to-work planning, and escalation pathways
• Partner with leadership on high-risk or sensitive claims as needed

TPA, Medical & Stakeholder Coordination
• Serve as a primary point of contact for complex claims with Third-Party Administrators (TPAs), adjusters, and Nurse Case Managers
• Coordinate claim strategy, medical treatment plans, and return-to-work opportunities
• Ensure timely and accurate communication between internal stakeholders and external partners

Return-to-Work & Complex Case Coordination
• Oversee return-to-work strategies for complex or extended claims
• Provide guidance on complex work restrictions and accommodations

Documentation Oversight & Quality Assurance
• Support implementation of process improvements to enhance efficiency and claim outcomes
• This position requires participation in an on-call rotation. Employees must be available to respond to work-related calls, messages, or emergencies outside of regularly scheduled working hours as assigned. The employee is expected to maintain reliable communication access and be able to report to work or perform duties remotely within a reasonable response time when on call.
• Complies with all applicable federal, state, and local laws, regulations, and company policies
• Performs other duties as assigned to support departmental and organizational objectives.

REQUIRED QUALIFICATIONS
• High school diploma or equivalent
• 5+ years of workers' compensation orclaims management experience
• Experience managing complex orescalated claims, including extended orhigh-risk cases
• Strong understanding of claim lifecycle,medical management, and return-to-workpractices
• Ability to analyze claim trends, identifyrisk factors, and make informed decisions
• Demonstrated ability to mentor or support junior team members

PREFERRED QUALIFICATIONS
• Bachelor's degree in Business, Risk Management, HR, or related field
• Professional certifications (e.g., AIC, WCCP, ARM, or similar)
• Experience working with litigated claims or complex medical cases
• Experience participating in claim review meetings or strategy discussions
• Advanced knowledge of OSHA and regulatory compliance

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