NY Claim Specialist II - Hybrid Role

<strong>Personal, compassionate service is what we&rsquo;re known for at NJM. We seek the best and brightest to help our customers when they need us most. As part of the NJM team, you'll not only enjoy some of the best benefits in the industry, you'll also be joining a company that's committed to professional development, diversity and innovative thinking.</strong><br /><br /><strong>What is it like to work at NJM?&nbsp; Click <a href="https://www.youtube.com/watch?v=6XVn3U0XK-0&amp;feature=emb_logo" target="_blank" title="Video" rel="noopener noreferrer">here</a> to see!<br /><br />If you don't see the position you are looking for, apply <a href="https://njm.wd1.myworkdayjobs.com/en-US/njm/introduceYourself" target="_blank" title="Introduce Yourself" rel="noopener noreferrer">here</a>.<br /></strong>

Parsippany

NJM Insurance

<p><strong>This isn&rsquo;t just insurance.&nbsp; It&rsquo;s NJM.</strong></p> <p>When you join the NJM family, you&rsquo;ll work with talented people who care about doing the right thing by our policyholders as well as each other. You&rsquo;ll be part of a financially strong and stable company that has flourished on relationships, integrity and service for more than a century. NJM is a special place where you can propel your career, help others and make friends &ndash; all at the same time.&nbsp;</p> <p>NJM is proud to offer our employees continuous learning options, outstanding benefits, access to wellness programs, and a wide range of opportunities to give back to the communities we are privileged to serve.&nbsp;</p> <p>Leading, independent consumer publications repeatedly recognize our commitment to customer and claims satisfaction. In addition, NJM has been named to the Forbes list of the Best Employers in New Jersey three years in a row, based on feedback directly from our employees.</p> https://www.njm.com/about/careers

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Full

Overview: <p>NJM&rsquo;s Workers&rsquo; Compensation Claims Team is seeking a New York Regional Claim Specialist, Level II. This is a full-time position and offers a hybrid schedule after training, working from home 3 days per week.</p> <p>This role will be based in our <u>Parsippany, NJ</u> office location.</p> <p><strong>Schedule:</strong> Monday-Friday, specific hours are subject to selected start time between 8:00am-8:45am pending supervisory approval.</p> <p><strong>Salary Range:</strong> $ 75,000 - $87,000. Salary is commensurate with experience and credentials.</p> <p><strong>Job Description</strong></p> <p>The NY Regional Claim Specialist 2 will be responsible for contacting all parties involved in the claim, gathering, and securing all necessary information to effectively evaluate the claim, and outlining and recommending an action plan to manage the claim. The NY Regional Claim Specialist 2 will work with and communicate to all internal and external stakeholders, including:&nbsp; 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. This role requires consistent application of claims best practices to meet and exceed state compliance requirements.</p>
Responsibilities: <ul> <li>Manage litigated claims through proactive execution of action plans</li> <li>Manage and resolve issues on litigated cases, inclusive of evaluating claim exposure, negotiating, and resolving claims via Section 32 settlements, SLU stipulations, and permanency decisions</li> <li>Recommend process improvement where applicable to best improve the department efficiency, work product, and service commitment to interested parties</li> <li>Ensure quality management of claims in accordance with claims best practices and company guidelines, and timely, accurate documentation of claim activity</li> <li>Provide a high level of customer service, including providing excellent communication with all stakeholders (injured workers, providers, attorneys, brokers, clients, etc.)</li> <li>Determine compensability and coverage issues by gathering medical and factual evidence</li> <li>Administer the delivery of timely, appropriate, and accurate indemnity and medical benefits while strictly adhering to NY regulations, payor compliance, and medical treatment guidelines</li> <li>Evaluate the claim for potential fraud indicators and escalate the file to SIU, as appropriate</li> <li>Recognize and investigate subrogation opportunity for recovery of third-party funds</li> <li>Identify claims for legal referral, collaborate with Defense Counsel when indicated, and work to resolve the claim within given authority</li> <li>Monitor eCase for hearing dates and review hearing reports throughout the legal and/or settlement process to maintain the best interest of the Policyholder and NJM</li> <li>Secure Medicare set-asides and annuities as required</li> <li>Assist the Reserve Department to ensure accurate reserves through recognition of significant events or changes throughout the claim&rsquo;s life cycle</li> <li>Work with the NY PAR system (OnBoard) and/or through a vendor to manage PAR requests</li> <li>Determine injured worker indemnity benefit eligibility and conform to NY Payer Compliance Regulations</li> <li>Adhere to strict data integrity standards to appropriately trigger filings within the NY EDI system</li> <li>Perform verification of all prior decisions and awards to determine the accuracy of calculations</li> <li>Work in conjunction with members of the Claims Support Department to obtain and confirm information on the awards currently due</li> <li>Investigate and analyze the loss event, the injury, and the relevant information to make a compensability determination within 25 days from the date of the Board Indexing and recommend a course of action</li> <li>Build rapport with the policyholder, conduct on-site investigations when necessary, and educate the policyholder on NJM legal procedures, policies, and claim practices</li> <li>Send all appropriate documentation, regulatory forms, and medical release authorization within the Board&rsquo;s prescribed period of time</li> <li>Work independently with minimal supervisory oversight to maintain general compliance and data integrity</li> <li>Prepare, attend, and participate in Claim Reviews as needed with the Claims Supervisor</li> <li>Maintain awareness of relevant NY regulatory changes which affect claims handling processes and procedures</li> <li>Demonstrate a commitment to NJM&rsquo;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</li> </ul>
Requirements: <ul> <li>3-5 years&rsquo; experience as a Regional Workers&rsquo; Comp Claim Representative, or comparable insurance knowledge and experience with various aspects of claims handling and processes</li> <li>Intermediate knowledge of the NY WC system as applicable to make compensability decisions</li> <li>Ability to formulate an Action Plan to bring claims to resolution</li> <li>Experience working with liens and Medicare Set-Asides to secure full and final settlements</li> <li>Customer service oriented with strong written and oral communication skills</li> <li>Strong interpersonal skills with ability to work both in a team and independently</li> <li>Demonstrated organizational skills, and use of sound decision-making capabilities</li> <li>Working knowledge utilizing an automated claim processing system and the Microsoft Office suite of tools (Word, Excel)</li> <li>Ability to travel for business purposes, approximately less than 10%</li> </ul> <br /><strong>Preferred:</strong><br /> <ul> <li>Multi-state experience and/or licensing (including NJ, MD, CT, DE, PA and/or NY)</li> <li>Associate&rsquo;s or Bachelor&rsquo;s degree</li> <li>AIC/CPCU Designations</li> </ul>