NJM's Workers' Compensation Claims Team is seeking an experienced Complex Claim Specialist. This is a full-time position and offers a hybrid schedule after training. The Complex Claim Specialist 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 to final resolution. The Complex Claim Specialist 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. This position may manage select Catastrophic (CAT) losses assigned by the Complex Claims Supervisor for developmental purposes.
This role can be based in NJM's Hammonton, NJ or West Trenton, NJ office location.
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
Investigate and analyze coverage and the loss event after gathering medical and factual evidence to make a compensability determination and formulate an action plan
Authorize and issue indemnity payments and evaluate the appropriateness of making a voluntary offer of partial permanent disability (PPD)
Proactively manage the technical aspects of complex and high severity medical and CAT claims for quality outcomes and return to work opportunities under the regular guidance of Complex Claims Supervisor
Ensure quality management of claims in accordance with claims best practices and company guidelines, and timely, accurate documentation of claim activity
Collaborate with the Nurse Case Manger (NCM) to resolve issues and authorize quality care for the injured worker
Evaluate the claim for potential fraud and escalate the file to SIU, as appropriate
Must provide excellent communication and work collaboratively with multiple partners (insureds, injured workers and their families, doctors, rehabilitation experts, vendors, brokers, and attorneys) to successfully manage medical and rehabilitation issues
Build rapport with the policyholder, conduct on-site investigations, educate the policyholder on NJM procedures, policies, and claim practices, and evaluate the policyholder's reporting practices
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: Level II: 5-8 years' work experience as a NJ Workers' Comp Claim Representative with an emphasis on legal knowledge. Demonstrated knowledge of legal approaches, terminology, and applicable case law.
Senior Level: 8+ years' work experience as a NJ Workers' Comp Claim Representative with an emphasis on legal knowledge. Strong 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, and completing settlement evaluations (S20/ OAS)
Strong interpersonal skills with ability to work both in a team setting and independently
Demonstrated organizational skills and use of sound decision-making capabilities
Proficient 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: 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: Level II - $64,000 - 81,000
Senior Level - $77,000 - 89,000
Salary is commensurate with 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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