Complex Claim Specialist

5 days ago

Trenton, United States NJM Insurance Group Full time

**Personal, compassionate service is what we’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.**-
- 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.- Overview

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.

**Salary**:

- **Level II - **$64,000 - 81,000
- **Senior Level - **$77,000 - 89,000

Salary is commensurate with experience and credentials.-
- 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. Authorize and issue indemnity payments and evaluate the appropriateness of making a voluntary offer of partial permanent disability (PPD).
- Investigate and analyze coverage and the loss event after gathering medical and factual evidence to make a compensability determination and formulate an action plan. Prepare, attend, and participate in Claim Reviews as needed with the Claims Supervisor.
- 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. Participate in training programs to keep current on relevant issues/topics.- Overview
- 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,

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