Claims Specialist III- WC

UFG Insurance•Dallas, TX

6d•Remote

About The Position

UFG is currently hiring for a Claims Specialist III in Workers Compensation. This role is a highly experienced position primarily responsible for verifying applicable coverages, conducting timely and thorough research of the facts of a loss, analyzing compensability and evaluating benefits for reserve and settlement, and negotiating medium to high complexity claims to resolution in accordance with claims best practices. The Claims Specialist III – WC role demonstrates a strong desire to learn and grow, promotes a positive work environment, and embraces a strong service-oriented mindset in support of internal and external customers. This role requires strong communication skills, attention to detail, and the ability to handle multiple tasks efficiently and effectively. It also requires the ability to work independently with a low level of supervision and a high level of accountability. A strong desire to advance one’s professional development and the development of others is essential to this role.

Requirements

High school diploma required.
5+ years of general work experience.
10+ years of workers’ compensation claims handling experience or a combination of workers’ compensation claims handling experience and experience in a related field.
Meet the appropriate state licensing requirements to handle claims.
Within 1 year of hire, complete the Workers’ Recovery Professional (WRP) certification program.
Within 3 years of hire, complete the Senior Workers’ Compensation Law Associate (SCLA) designation program.
Proficient knowledge of insurance, medical and legal concepts is required with a high degree of ability to articulate knowledge verbally and in writing.
Service-Oriented Mindset
Clear and Concise Communication
Analytical and Critical Thinking
Attitude of Collaboration and Curiosity
Proactive Decision-making and Problem-solving
Time management and Sense of Service Urgency
Demonstrate aptitude for mentorship and leadership
Actively leads execution of claims initiatives

Nice To Haves

Post-Secondary education or Bachelor’s degree preferred.
Willingness to pursue other professional certifications or designations as requested.

Responsibilities

Review claim assignments to timely determine policy coverage, compensability of a claimed injury or illness and facilitation of medical, indemnity and other statutory workers’ compensation benefits. If a coverage issue is relevant, review facts with a designated leader or mentor to determine a proper plan of action.
Make prompt, meaningful contact with insureds and their employees to research facts by conducting interviews; securing, understanding and synthesizing information from relevant documents; identifying other relevant parties to a claim; and proactively supporting all parties with their commitment to outcomes.
Establish rapport and an outcome focused relationship with insureds and their employees, as well as other internal and external stakeholders, through consistent on-going contact throughout the recovery process and claim resolution.
Request and analyze medical records to determine compensability according to evidence-based causation by jurisdiction. Have proficiency with conducting medical and legal research.
Interact with medical providers to clearly define medical causation and establish treatment plans focused on recovery.
Promptly and supportively inform insured and employees as well as other stakeholders of coverage and compensability decisions.
Support stay-at-work or return-to-work opportunities for insureds and their employees. Propose and facilitate vocational support when appropriate by jurisdiction.
Identify subrogation potential and document evidence in support of subrogation. Understand the subrogation mechanism and actively partner with internal and external subrogation partners to achieve outcomes with a goal to achieve global resolution.
Identify potential Medicare eligibility and comply with all Medicare Secondary Payor requirements of law. Have strong knowledge of Medicare settlement obligations.
Assess and periodically re-assess the nature and severity of injury or illness and design a plan of action focused on recovery and resolution in accordance with claims best practice guidelines by jurisdiction. Identify factors which could impact successful outcomes and collaborate on plans of action to mitigate impacts.
Assess and periodically re-assess claim file reserves to a high degree of accuracy. This will be achieved through understanding medical diagnoses and care plan developments; thorough analysis of wage information and accurate calculations of indemnity benefits; and by securing and providing job descriptions specific to the employee to medical providers. Promptly identify factors of risk for increased loss and expense costs.
Execute all technical claim handling functions such as documenting facts within the claims management system in a consistent, concise and clear manner; make timely decisions and promptly communicate decisions to stakeholders; process accurate benefit payments; and seek opportunities to mitigate claim handling expenses.
Proactively seek resolution of claims by defining stakeholder outcome expectations early and often, managing processes focused on outcomes and engaging in direct negotiation, mediation, settlement conferences or hearings according to jurisdiction. Proficient with seeking opportunities to overcome resolution barriers.
Comply with statute specific claims handling practices and reporting requirements.
Inform underwriting of increased hazards or unusual circumstances concerning a risk/policy exposure.
Participate in internal and external continuing education opportunities to maintain licensure and develop claim handling skills and abilities.
Demonstrate a supportive attitude and presence within the team by adapting well to change in process or procedure. Share innovative ideas to improve work product and outcomes. Take initiative to identify and learn about areas of professional development. Proactively seek out opportunities to collaborate with peers.
Demonstrate interest in one’s own career development and actively support peers with their development.
This role requires a strong understanding of the insurance mechanism and interactions between business functions as well as strong support for initiatives that advance the goals of the enterprise.