Independently investigate, evaluate, negotiate, manage, and resolve complex workers' compensation claims in a good faith manner..
Serve as a subject matter expert for workers' compensation regulations, claim handling best practices, and emerging industry trends.
Analyze medical, legal, vocational, and financial information to determine reserves, compensability, liability exposure, and settlement opportunities.
Provides recommendations to management regarding litigation, settlement authority, and risk mitigation.
Partner with legal counsel, medical providers, third-party administrators, brokers, and regulatory agencies to facilitate claim resolution.
Perform quality reviews and audits of claim files to ensure consistency, compliance, and adherence to organizational standards.
Act as a mentor and resource for Claims Analysts I and II, providing coaching, knowledge transfer, and claims guidance.
Lead special projects, process improvement initiatives, and cross-functional efforts related to workers' compensation operations.
Maintain accurate documentation and timely claim handling activities in accordance with company standards and jurisdictional requirements.
Demonstrates advanced proficiency in leveraging emerging technologies, automation tools, and AI resources to optimize claim handling operations, drive process improvements, and elevate customer service outcomes.
Serves as a resource to others by promoting technology adoption, identifying innovative solutions, and influencing best practices that improve efficiency, accuracy, and organizational performance.
Knowledge and Requirements:
High School Diploma or GED required. Bachelor's degree in Business, Risk Management, Insurance, Human Resources, or related field preferred.
Minimum 5+ years of workers' compensation claims handling experience.
Demonstrated experience handling complex, litigated, and high-exposure workers' compensation claims.
Advanced knowledge of workers' compensation laws, regulations, and claims practices across multiple jurisdictions.
Proven ability to independently manage large claim inventories and complex investigations.
Strong analytical, negotiation, and decision-making skills.
Excellent written and verbal communication skills.
Advanced proficiency with claims management systems and Microsoft Office applications.
Ability to exercise sound judgment and discretion in sensitive situations.
Travel as needed to customer locations, hearings, mediations, or claim-related meetings.
Associate in Claims (AIC), CPCU, ARM, WCP, or other industry designation preferred.