Claims Resolution Specialist

2 weeks ago

West Trenton, United States NJM Insurance Group Full time

The Claim Resolution Specialist 1 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 Claim Resolution Specialist 1 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. In coordination with the Claim Resolution Supervisor, make recommendations for medical, voluntary offers of permanent partial disability (PPD), and seek authority as needed. This role will manage litigated claims of low complexity for further development within this track.

This role can be based in any of NJM’s New Jersey office locations**:West Trenton, Hammonton, or Parsippany.**

**Responsibilities**:

- 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
- Manage workers’ compensation claims through proactive execution of action plans to resolve claim and legal issues and move cases toward closure
- Ensure quality management of claims in accordance with claims best practices and company guidelines, and timely, accurate documentation of claim activity
- Work with NJM Legal to resolve the claim within given authority
- Determine compensability and coverage issues that have been placed in litigation by gathering medical and factual evidence
- Administer the delivery of timely, appropriate, and accurate indemnity and medical benefits
- Develop a litigation plan with NJM Legal to control legal expenses and assure effective resolution of claims to reduce aged inventory
- Work closely with NJM Legal on litigated cases, and attend mediation, settlement conferences, and hearings as necessary to resolve issues and close cases
- Contact and engage with plaintiff law firms to bring resolution to the case inclusive of dismissals and settlements
- Maintain knowledge of new and existing relevant laws and regulations, taking appropriate action to ensure timely compliance and communication to appropriate departments
- Evaluate the claim for potential fraud indicators and escalates the file to SIU, as appropriate
- Coordinate with other NJM resources to successfully resolve and/or settle cases in a timely fashion
- Prepare, attend, and participate in Claim Reviews as needed with the Claims Supervisor
- Participate in training programs to keep current on relevant issues/topics

**Required Qualifications and Experience**:

- 3-5 years’ work experience as a NJ Workers' Comp Claim Representative with an emphasis on legal knowledge
- Basic knowledge of legal approaches, terminology, and applicable case law
- Customer service oriented with strong written and oral communication skills and ability to work both in a team setting and independently
- Critical thinking skills that demonstrate analysis/judgment and sound decision making with focus on attention to details
- Experience in deciding compensability issues, inclusive of medical causal relationship
- Strong interpersonal skills with ability to work both in a team setting and independently
- Demonstrated organizational skills and use of sound decision-making capabilities
- Strong knowledge utilizing an automated claim processing system and the Microsoft Office suite of tools (Word, Excel)
- Ability to travel for business purposes, approximately less than 10%

**Preferred**:

- Experience in completing settlement evaluations (S20/ OAS)
- Multi-state experience and/or licensing (including NJ, MD, CT, DE, PA and/or NY)
- Associate’s or Bachelor’s degree
- AIC/CPCU Designations

**Salary Range**: $55,000 - $70,000. Salary is commensurate with experience and credentials.

This role may be filled at a Level II or Senior level based on skills, experience and credentials.

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.

Pay: From $55,000.00 per year

**Benefits**:

- 401(k)
- 401(k) matching
- Dental insurance
- Health insurance
- Paid time off
- Vision insurance

Schedule:

- Monday to Friday

Work setting:

- Office

Application Question(s):

- Please provide your salary requirement.
- Will you be able to reliably commute to one of NJM's office locations listed in the job description?

Work Location: Hybrid remote in West Trenton, NJ 08628

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