Regional Claims Specialist II

<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=";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="" target="_blank" title="Introduce Yourself" rel="noopener noreferrer">here</a>.<br /></strong>


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>

keywords: position summary,position details,planning,goals,claims,compliance,customer service,performance,qualifications,knowledge,skills,preferred

Full time

Overview: The 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 Regional Claim Specialist 2 will work with and communicate to all internal and external stakeholders, including: 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 is an intermediate level position in the Regional Claim track that will require basic supervision, guidance and coaching in the skill development of the role.
Responsibilities: <ul> <li>Execute on strategic and operational goals and objectives of the WCC department and company business goals, guidelines, and programs.</li> <li>Recommend process improvement where applicable to best improve the department efficiency, work product, and service commitment to interested parties.</li> <li>Effectively manage litigated claims through proactive execution of action plans to resolve claim issues to move cases toward closure and reduce aged inventory.</li> <li>Will develop plans of action for the exploration of early RTW programs, MMI status, and with Supervisor guidance, legal and settlement of cases to resolve timely and for best outcomes.</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 that promotes injured worker advocacy-based principles to maximize return to work motivation and improve outcomes for all parties.</li> <li>Investigate and 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.</li> <li>Evaluate the claim for potential fraud indicators and escalates the file to SIU, as appropriate.</li> <li>Recognize and investigate subrogation opportunity for recovery of third-party funds.</li> <li>Initiate and provide excellent communication with all stakeholders (injured workers, providers, attorneys, brokers, clients, etc.) professionally and proactively with a customer-centric approach.</li> <li>Apply critical thinking skills to evaluate and mitigate exposures, and establish and implement a proactive strategic plan of action.</li> <li>Identify claims for legal referral and collaborate on settlement strategies with Defense Counsel.</li> <li>Promptly manage and resolve issues on litigated cases, inclusive of evaluating claim exposure, negotiating, and resolving claims.</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>Prepare, attend, and lead Claim Reviews as needed with the Claims Supervisor.</li> <li>Assist in the preparation and utilization of Medicare Set-asides and annuities to bring cases to a full and final closure.</li> <li>Participate in in-house and outside training programs to keep current on relevant issues/topics.</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&nbsp;claims handling and processes.</li> <li>Intermediate knowledge of WC regulations and jurisdiction(s) to be able to formulate an action plan to bring claims to resolution.</li> <li>Intermediate through demonstrated knowledge of understanding 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>Proficient knowledge utilizing an automated claim processing system and the Microsoft Office suite of tools (Word, Excel)</li> <li>Adjuster License as required.</li> <li>Ability to travel for business purposes, approximately less than 10%.</li> <li>High School Diploma or GED.</li> </ul> <p>&nbsp;</p> <p><strong>Preferred:</strong></p> <ul> <li>Multi-state experience and/or licensing (including NJ, MD, CT, DE, PA and/or NY).</li> <li>Associate or Bachelor&rsquo;s degree.</li> <li>Possible completion of classes toward insurance industry designations including but not limited to AIC and/or CPCU.</li> </ul> <p>&nbsp;</p> <p><strong>Level of Authority:</strong></p> <ul> <li>Work with defense counsel to resolve the claim within given authority.</li> </ul> <p>&nbsp;</p> <p>&nbsp;</p> <p>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.</p>