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Job Description SummaryUnder moderate supervision, investigate compensability of questionable Workers Compensation claims, manage claims with lost time to conclusion and negotiate settlements where appropriate to resolve claims. Coordinate medical and indemnity position of the claim with a Medical Case Manager. This work may include: Remains out of work and unlikely to return to position. Employer is unable to accommodate the restrictions. Injured Worker(IW) has returned to work, reached Maximum Medical Improvement (MMI), and has PPD. File litigated to dispute the permanency rating and/or causality. IW has been released to work with permanent restrictions and job is no longer available. IW is receiving Vocational Rehabilitation. Claims that have been reopened for additional medical treatment on more complex files. Injuries may involve one or multiple back, shoulder or knee surgeries, knee replacements, claims involving moderate to complex offsets, permanent restrictions and/or fatalities. Claims on which a settlement should be considered. As part of the hiring process, this position requires the completion of an online pre-employment assessment. Further information regarding the assessment including an accommodation process, if needed, will be provided at such time as your candidacy is deemed appropriate for further consideration.
Primary Job Duties & Responsibilities
- Conduct investigations on non-questionable/questionable claims, including, but not limited to assessing policy coverage, contacting insureds, injured workers, medical providers, and other parties in a timely manner to determine compensability.
- Establish and update reserves to reflect claim exposure and document rationale. Identify and set actuarial reserves.
- Apply knowledge to determine causal relatedness of medical conditions.
- Achieve a positive end result by returning injured party to work and coordinating the appropriate medical treatment in collaboration with our internal nurse resources where appropriate.
- If controverted or coverage is unconfirmed, retain and manage assigned claims to conclusion.
- Prepare necessary letters and state filings within statutory limits.
- Proactively manage inventory with documented plans of action to ensure timely and appropriate file closing or reassignment.
- Facilitate timely claim resolution by leveraging any mitigation opportunities.
- Manage litigation to drive files to an optimal outcome.
- Understand and apply Medicare Set Asides and allocations.
- Negotiate settlement of claims within designated authority. May use structured settlement/annuity as appropriate for the jurisdiction.
- Pursue all offset opportunities, including apportionment, contribution and subrogation.
- Evaluate claims for potential fraud.
- Customer Engagement.
- Participate in Telephonic and/or onsite File Reviews.
- Respond to inquiries - verbal and written.
- Keeping injured worker apprised of claim status.
- May handle Critical Claims as outlined below:
- Work in collaboration with specialty resources (e.g. medical, legal) to manage medical treatment and lost time benefits in cases involving extremely complex issues or potentially high financial exposure.
- Develop strategies to manage losses involving complex issues of statutory benefit entitlement, medical diagnoses, Medicare Set Aside or injury severity to achieve resolution through the best possible outcome.
- Co-manage appropriate claims with the Major Case Unit, who will assist with disability and treatment projections; reserving; and investigative suggestions on complex or catastrophic losses.
- Engage specialty resources as needed.
- Act as technical resource to others.
- In order to perform the essential functions of this job, acquisition and maintenance of Insurance License(s) may be required to comply with state and Travelers requirements. Generally, license(s) must be obtained within three months of starting the job and obtain ongoing continuing education credits as mandated.
- Maintain Continuing Education requirements as required.
- Other duties as assigned.
- High school diploma or equivalent required.
- Minimum of 2 years Workers Compensation claim handling experience.
Education, Work Experience, & Knowledge
- College degree preferred.
- 3+ years Workers Compensation claim handling experience preferred.
Job Specific Technical Skills & Competencies
- Analytical Thinking: Identifies current or future problems or opportunities; analyzes, synthesizes and compares information to understand issues; identifies cause/effect relationships; and explores alternative solutions that support sound decision-making.
- Communication: Expresses, summarizes and records thoughts clearly and concisely orally and in writing by applying proper content, format, sentence structure, grammar, language and terminology. Ability to effectively present file resolution to internal and/or external stakeholders.
- Negotiation: Advanced evaluation, negotiation and case resolution skills. Ability to understand alternatives, influence stakeholders and reach a fair agreement through discussion and compromise.
- Thorough Insurance Contract Knowledge: Interprets policies and contracts, applies loss facts to policy conditions, and determines whether or not a loss comes within the scope of the insurance contract.
- - Principles of Investigation: Intermediate investigative skills including the ability to take statements. Follows a logical sequence of inquiry with a goal of arriving at an accurate reconstruction of events related to the loss.
- Value Determination: Advanced ability to determine liability and assigns a dollar value based on damages claimed and estimates, sets and readjusts reserves.
- Settlement Techniques: Intermediate ability to assess how a claim will be settled, when and when not to make an offer, and what should be included in the settlement offer package.
- Legal Knowledge: General knowledge, understanding and application of state, federal and regulatory laws and statutes, rules of evidence, chain of custody, trial preparation and discovery, court proceedings, and other rules and regulations applicable to the insurance industry.
- Medical knowledge: General knowledge of the nature and extent of injuries, periods of disability, and treatment needed.
- WC Technical:
- Intermediate ability to demonstrate understanding of WC Products and ability to apply available resources and technology to resolve claims. Demonstrate a clear understanding and ability to work within jurisdictional parameters within their assigned state.
- Customer Service:
- Advanced ability to build and maintain productive relationships with our insureds and deliver results with optimal outcomes
- Advanced ability to work together in situations when actions are interdependent and a team is mutually responsible to produce a result
- Planning & Organizing:
- Advanced ability to establish a plan/course of action and contingencies for self or others to meet current or future goals
Environmental / Work Schedules / Other
- Operates standard office equipment (Frequency)
- Sitting (can stand at will) (Frequency)
- Use of Keyboards, Sporadic 10-Key (Frequency)
Travelers is an equal opportunity employer. We value the unique abilities and talents each individual brings to our organization and recognize that we benefit in numerous ways from our differences.
If you have questions regarding the physical requirements of this role, please send us an email so we may assist you.
Travelers reserves the right to fill this position at a level above or below the level included in this posting.