BASIC PURPOSE:
In accordance with application of state and federal laws and company best practices and under limited supervision, responsible for the investigation, evaluation, and disposition of complex Workers Compensation cases of high exposure and severity. Gather and review claim information, determine coverage, and conduct investigation. Initiate and maintain customer contact to provide updates and resolve any issues with the claim. Update information in the claim system to document claim handling activities. Determine/set reserves and make payments within level of authority. Applies established medical management strategies in high dollar complex claims. Direct work of defense attorneys. Investigate and refer identified claims to Loss Recovery Services as applicable. Has developed high level of knowledge of Workers Compensation claims handling techniques and is cognizant of new industry trends and claim handling techniques.
PRIMARY JOB RESPONSIBILITIES:
- Perform claim tasks timely and document claim files appropriately. Proactively manage claim activities to ensure fair claim resolution. Handle all claims in accordance with state and federal laws.
- Apply advanced expertise in jurisdictional knowledge for full compliance with jurisdiction regulations for all claims across all jurisdictions assigned. Timely incorporates jurisdictional regulatory changes to daily processes, ensuring continuous regulatory compliance.
- Make complex coverage and/or compensability decisions by gathering information necessary to make an informed decision in a fair, equitable, and ethical manner. Deny losses within authority level, providing detailed explanation, citing facts, and statutory language. Evaluate subrogation potential based on the applicability of policy language and/or governing state laws and statutes as appropriate.
- Perform a thorough investigation based upon the type, complexity, and severity of the claim. Upon completion of the investigation, analyze and evaluate the potential exposure and damages, including potential full or partial liability, compensability denials, and subrogation potential as applicable. Formulate and document an action plan based on the intended resolution strategy.
- Determine and set reserves based on the most probable outcome of the claim, within authority level. Evaluate and negotiate directly with insured, claimant, or claimant's attorney on all cases within authority level. Review claim facts and exposure with claims management, as appropriate, to guide claim strategy. Make complete, accurate, and timely payments within authority for covered losses.
- Identifies and appropriately handles claims with MSA (Medicare Set Aside) exposure.
- Recognize when vendor partners are required on a claim, including experts, nurses, defense attorneys, etc. Assign and direct vendors, as needed, to aid in the investigation and evaluation of the claim. Manage claim expenses by concluding vendor assignment when vendor is no longer adding value to the claim.
- Maintain a professional, courteous, and helpful approach when communicating in person, on the phone, through email, and other correspondence with internal and external customers, business partners, and brokers.
- Coordinates and participates in training sessions for less experienced staff. Act as a resource to share in depth knowledge and experience with other claim handlers including jurisdictional expertise. Assist and support their development with mentoring and auditing functions.
- Investigate and refer identified claims to loss recovery services, as applicable.
- Direct work of defense attorney through collaboration on claim strategy and resolution. Ensure defense attorney is adhering to litigation management guidelines. Manage claim expenses by reviewing attorney/firm performance, results and the value of services provided.
- Engage in direct investigation, control, and settlement negotiations when outside adjusting and legal services are not necessary or available.
- Attend mediations as requested.
- Demonstrates the ability to understand key data elements and claims related data analysis.
- Present complex claims files as requested and prepare large loss reports per internal protocols seeking approval from executive management.
- Stay abreast of current and emerging jurisdictional case law and regulatory changes with appropriate application to claims. Actively communication and share potential impacts with key CM Group stakeholders.
QUALIFICATIONS:
- Bachelor's degree preferred. A combination of equivalent education and/or experience may be considered in lieu of a degree.
- Evidence of continuing education in the insurance industry is preferred.
- Completion of AIC and/or CPCU is preferred.
- Experience handling claims across multiple jurisdictions. Preferred CA expertise, willing to consider GA, TN, IN as well.
- Minimum of eight years in technical insurance claim roles with increasing responsibilities is required.
- Ability to obtain and maintain state adjusting license requirements and complete continuing education requirements.
- Advanced knowledge of recoveries such as subrogation, reinsurance, apportionment, and deductibles.
- Advanced knowledge of second injury funds, reinsurance etc.
- Advanced negotiation skills.
- Strong listening, verbal, and written communication skills.
- Evidence of ability to think independently.
- Advanced knowledge of policy terminology, legal principles involving insurance, and emerging industry trends.
- Effective planning and organization skills.
- Advanced knowledge of policy terminology and legal principles involving insurance, and emerging industry trends.
WORK ENVIRONMENT:
Professional office environment.
NOTE: This job description in no way states or implies that these are the only duties performed by this employee. Employees may be requested to perform job-related tasks other than those specifically presented in this job description. The employer reserves the right to change or assign other duties to this position.
The CM Group is made up of Church Mutual Insurance Company, S.I., CM Regent Insurance Company, CM Vantage Specialty Insurance Company and CM Select Insurance Company.
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