Claims Account Specialist I

Claims Account Specialist (I)

The Workers Compensation department is searching for a Claims Account Specialist. The Claims Account 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.

The Claims Account Specialist will work with and communicate to NJM policyholders, injured workers, medical providers, NJM Medical Services Administration Department, the NJM Special Investigation Unit, WC Legal Staff, other departments within NJM, and vendors as needed. This is an entry level position in the Claims Account track that will require consistent supervision, guidance and coaching in the skill development of the role.

Hours :

Monday-Friday, specific hours are subject to selected start time between 8am-9am pending supervisory approval

Essential Duties and Responsibilities :

Execute on strategic and operational goals and objectives of the WCC department and company business goals, guidelines, and programs

Recommend process improvements where applicable to improve department efficiency, work product, and service commitment to interested parties

Ensure quality management of claims in accordance with claims best practices and company guidelines, proactive action plans to drive positive return to work results while presenting timely, accurate documentation of claim activity

Investigate and analyze the loss event, injury, and relevant information to make a compensability determination and recommend a course of action

Administer the delivery of timely, appropriate, and accurate indemnity and medical benefits

Provide a high level of customer service that promotes injured worker advocacy-based principles to maximize return to work motivation and improve outcomes for all parties

Recognize and investigate subrogation opportunity for recovery of third-party funds

Work with the policyholder and NJM Loss Control to assist and develop stay at work / return to work efforts

Investigate potential fraud indicators in collaboration with the SIU team

Initiate and provide excellent communication with all stakeholders (injured workers, providers, attorneys, brokers, clients, etc.) professionally and proactively with a customer-centric approach

Consistently question and probe all aspects of assigned claims to achieve full understanding of facts

Comply with, and conduct all activities within state WC claims laws and fair practices, NJM's Code of Ethics, and NJM's Best Practices and Policies

Build rapport with the policyholder, educate the policyholder on NJM procedures, policies, and claim practices, and evaluate the policyholder's reporting practices

Include accountability in managing service expectations and rapport and trust with assigned large accounts

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 :

Level I - 0-3 years' of experience as a Workers' Comp Claim Representative, or comparable knowledge and experience with various aspects of claims handling and / or process including basic knowledge of WC Law, medical terminology, and utilization of an automatic claims processing system.

Ability to manage return to work expectations with employers, doctors, and injured workers

Strong written and oral communication skills with ability to work both in a team setting and independently

Sound decision-making and critical thinking capabilities

Demonstrated organizational and communication skills

Superior customer service skills and ability to engage in business interactions with a polite, courteous, and professional manner

Working knowledge of 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 or bachelor's degree

AIC / CPCU Designations

Compensation : Salary is commensurate with experience and credentials.

Pay Range : $49,871-$57,881

Eligible full-time employees receive a competitive Total Rewards package, including but not limited to a 401(k) with employer match up to 8% and additional service-based contributions, Health, Dental, and Vision insurance, Life and Disability coverage, generous PTO, Paid Sick Leave, and paid parental leave in addition to state-mandated leave. Employees may also be eligible for discretionary bonuses.

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.