Claims Specialist - Workers' Compensation (California)

The Claims Specialist position is responsible for handling complex claims with a focus on providing exceptional service for stakeholders in order to drive claims to an equitable resolution within Company standards.  The Claims Specialist works with a sense of urgency, understands insurance coverage concepts, and navigates the legal system with the support of counsel to drive strategic outcomes.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Manages complex claims inventories requiring advanced technical expertise and strategic claim handling  

• Effectively communicates with policyholders, agents, attorneys, and witnesses to gather information and provide the highest possible level of customer service.

• Promptly investigates claims to determine exposure, works with appropriate experts and makes strategic recommendations.

• Utilizes appropriate resolution tactics (e.g., mediation, negotiation, denial, litigation or offer) to proactively drive outstanding results.

• Operates within the requirements of related state and/or the governing entity rules and regulations as well as internal claims handling policies and procedures. 

• Directs defense counsel throughout the litigation process in line with ICW litigation guidelines while monitoring legal fees and costs.

 All Claims Specialists:

• Consistently provides exceptional customer service

• Effectively collaborates with cross-functional Team Members for project and process discussions

• Makes recommendations for streamlining processes and adopting the industry’s best practices

• Ensures accuracy of data in claims system for compliance with applicable regulatory reporting

• Provides knowledge transfer across the organization

• Continuously seeks to improve technical skills by attending job related training and tracking current case law. 

• As a SME (subject matter expert), serves as a technical resource and mentors/trains less experienced Team Members

Workers’ Compensation Claims (Specific Responsibilities):

• Prepares and presents claims status reports for internal and external stakeholders.

• Administers timely and appropriate benefits to injured workers; manages and approves payment of benefits within designated authority level.  Works within applicable state rules, regulations as well as ICW Group’s internal claims handling policies and procedures.

• Creates and adjusts reserves in a timely manner to ensure reserving activities are consistent with company policies.

• Resolves claims fairly and equitably, acting in the best interest of the insured while providing timely benefits to injured workers as required by law.

• Supports specialty claim handling programs and strategic initiatives involving complex litigation, medical exposure, catastrophic injuries, fatality, PTD, or long-duration claims

• Provides technical guidance and collaborates with leadership on complex claim resolution strategies and specialty handling initiative

• Identifies and drives resolution opportunities on complex or long-duration claims through proactive settlement, reserving, and medical management strategies.

SUPERVISORY RESPONSIBILITIES

This position has no supervisory responsibility

EDUCATION AND EXPERIENCE

Bachelor's degree (or equivalent combination of education and experience) required along with a minimum of 8 – 10+ years’ related claims handling experience involving complex litigation, reserving, settlement strategy, and high exposure claims. 

CERTIFICATES, LICENSES, REGISTRATIONS

Workers’ Compensation: Certification that meets the minimum standards of training, experience, and skill required. WCCA and WCCP preferred. State Workers Compensation License is required in some branches.

KNOWLEDGE AND SKILLS

• Excellent understanding of laws and jurisdictional restraints to manage claims

• Excellent verbal communication skills, time management, attention to detail and organizational skills

• Must be adept at learning new technology

• Flexibility to adapt to changes in a fast-paced environment

Must have the ability to:

• Read, analyze, and interpret technical and legal documents

• Write reports and business correspondence

• Respond to common inquiries or complaints from customers (insured), claimants and regulatory agencies

• Present information at meetings, to management and clients

• Solve practical problems and deal with a variety of variables in situations where limited standardization exists

Workers’ Compensation: Advanced knowledge of workers’ compensation claims handling, reserving, litigation management, and resolution strategies

PHYSICAL REQUIREMENTS 

Office environment – no specific or unusual physical or environmental demands and employees are regularly required to sit, walk, stand, talk, and hear. 

This position operates in an office environment and requires the frequent use of a computer, telephone, copier, and other standard office equipment.

This description is a general statement of essential job functions and responsibilities.

The position may include other duties as assigned.