Claims Account Specialist, I

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.

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’ 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.