Worker's Compensation Examining Unit Manager

Dover, New Hampshire
Not Specified
Nov 18, 2020
Jan 17, 2021
Job Type
Not Specified
Career Level
Not Specified

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Direct Management of Examiners and/or catastrophic nurse case managers in the daily function of analyzing and evaluating high exposure WC Claims from several standpoints including Coverage, Compensability, Medical Exposure, Medical Mitigation, Vendor/Provider partnership and establishment of commensurate Reserves for Indemnity, Medical and Expense. Assists the Manager in the operation of the Examining and Catastrophic Case Manager Unit (CCMU). A significant portion of the duties will include direct supervision of a team of Examiners and/or catastrophic nurse case managers. The unit provides Claims Case Management and Medical/Disability direction to Field Claim Specialists, Managed Care Resources and provides evaluation of settlement values and reserve exposures and strategies on high exposure, catastrophic and complex claims. Multi-Region and/or Countrywide alignment/ responsibilities.


  • Manages a full range of claims files which include significant exposure and highly complex cases i.e., cases involving multiple plaintiffs or defendants, bankruptcy cases, catastrophic injury cases to determine proper coverage and oversee the resolution of coverage questions.
  • Reserves under management is generally $800m.
  • Participates in medium to long-term strategic business planning.
  • Leads and directs special projects for the line of business; prepares, recommends and manages to the office's annual budget to ensure appropriate resource allocations and expense levels.
  • Reviews significant exposure and complex files and maintains proper reserves on assigned cases/futurity.
  • Maintains a working reserve and settlement authority of $1,000,000; effectively, efficiently and accurately leveraging same to bring said complex/significant exposure claims to resolution while ensuring reserve/financial accuracy.
  • Provides top-tier customer experience for internal and external partners, including Claims, Managed Care, Examining, customers, and brokers.
  • Proactively engages and communicates with other departments to offer advice on the specifics, exposures, defenses and handling of significant exposure, complex or unique claims.
  • Acts as designee when requested by Manager and/or Senior Leadership to attend high level customer, regulatory, or business partner meetings.
  • Acts as a liaison on a multi-regional and/or country-wide basis between Examining, CCMU and the Region Managers to ensure coordination and joint efforts with the respective aligned Examining/CCMU team understanding region goals, challenges, objectives and strategies and being innovated in how to assist said region in achieving said goals/objectives.
  • Prepares reports and presents to superiors, other departments and outside personnel on the results, status and strategies on cases.
  • Participates as Subject Matter Expert (SME) and facilitates topics at seminars, conferences and workshops within and outside the claims department.
  • Facilitates and maintains vendor relationships as needed.
  • Provides on-site management and knowledge of files and areas of responsibility at the branch office level.
  • May negotiate settlements and provide recommendations on files above authority to department management and/or Senior Claims Leaders.
  • Proficient working knowledge of Medicare Compliance including MSAs, Section 111 Reporting, Conditional Payments.
  • Proficient working knowledge of Reversionary Interest, structured settlements, and professional administration.
  • Excellent verbal and written communication skills.
  • Lead and/or act as a Subject Matter Expert on cross-functional project teams.

  • Demonstrated ability to lead and manage a technical and medical tenured/experienced team of individuals in the oversight of significant exposure, catastrophic, complex and unique claims.
  • Ability to work well and in conjunction with large national account customers, understand special service instructions and build partnerships with Account/Service Managers, Underwriters, Distribution and Agents/Brokers. Extensive knowledge of Claims Department procedures and operations a plus.
  • A Bachelor`s degree or equivalent, 10+ years of related claims experience, and prior management experience required. RN Degree preferred, but not required.

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