Description
Job Description
The Claim Resolution Specialist 1 will be responsible for contacting all parties involved in the claim, gathering, and securing all necessary information to effectively evaluate the claim and implement an action plan to manage the claim. The Claim Resolution Specialist 1 will work with and communicate to NJM policyholders, injured workers, medical providers, the NJM Medical Services Administration Department, the NJM Special Investigation Unit, WC Legal Staff, and other departments within NJM, as well as outside defense counsel and vendors as needed. In coordination with the Claim Resolution Supervisor, make recommendations for medical, voluntary offers of permanent partial disability (PPD), and seek authority as needed. This role will manage litigated claims of low complexity for further development within this track.
This role can be based in any of NJM's New Jersey office locations: West Trenton, Hammonton, or Parsippany.
Responsibilities:
Execute on strategic and operational goals and objectives of the WCC department and company business goals, guidelines, and programs
Recommend process improvement where applicable to best improve the department efficiency, work product, and service commitment to interested parties
Manage workers' compensation claims through proactive execution of action plans to resolve claim and legal issues and move cases toward closure
Ensure quality management of claims in accordance with claims best practices and company guidelines, and timely, accurate documentation of claim activity
Work with NJM Legal to resolve the claim within given authority
Determine compensability and coverage issues that have been placed in litigation by gathering medical and factual evidence
Apply critical thinking skills to establish a strategic plan of action, evaluate and mitigate exposure and negotiate and resolve claims
Administer the delivery of timely, appropriate, and accurate indemnity and medical benefits
Develop a litigation plan with NJM Legal to control legal expenses and assure effective resolution of claims to reduce aged inventory
Work closely with NJM Legal on litigated cases, and attend mediation, settlement conferences, and hearings as necessary to resolve issues and close cases
Contact and engage with plaintiff law firms to bring resolution to the case inclusive of dismissals and settlements
Maintain knowledge of new and existing relevant laws and regulations, taking appropriate action to ensure timely compliance and communication to appropriate departments
Evaluate the claim for potential fraud indicators and escalates the file to SIU, as appropriate
Coordinate with other NJM resources to successfully resolve and/or settle cases in a timely fashion
Prepare, attend, and participate in Claim Reviews as needed with the Claims Supervisor
Participate in training programs to keep current on relevant issues/topics
Demonstrate a commitment to NJM's Code of Business Conduct and Ethics, and apply knowledge of compliance policies and procedures, standards, and laws applicable to job responsibilities in the performance of work
Required Qualifications and Experience:
3-5 years' work experience as a NJ Workers' Comp Claim Representative with an emphasis on legal knowledge
Basic knowledge of legal approaches, terminology, and applicable case law
Customer service oriented with strong written and oral communication skills and ability to work both in a team setting and independently
Critical thinking skills that demonstrate analysis/judgment and sound decision making with focus on attention to details
Experience in deciding compensability issues, inclusive of medical causal relationship
Strong interpersonal skills with ability to work both in a team setting and independently
Demonstrated organizational skills and use of sound decision-making capabilities
Strong knowledge utilizing an automated claim processing system and the Microsoft Office suite of tools (Word, Excel)
Ability to travel for business purposes, approximately less than 10%
Preferred:
Experience in completing settlement evaluations (S20/ OAS)
Multi-state experience and/or licensing (including NJ, MD, CT, DE, PA and/or NY)
Associate's or Bachelor's degree
AIC/CPCU Designations
Salary Range: $55,000 - $70,000. Salary is commensurate with experience and credentials.
This role may be filled at a Level II or Senior level based on skills, experience and credentials.
Legal Disclaimer: NJM is proud to be an equal opportunity employer. We are committed to attracting, retaining and promoting a diverse and inclusive workforce that is fully representative of the diversity that exists in the communities in which we do business.
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