Claims Specialist II - WC

UFG is currently hiring for a Claims Specialist II to work with our Workers Compensation team. This individual's 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 occasional high complexity claims to resolution in accordance with claims best practices.

The Claims Specialist II – Workers Compensation 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 low to moderate levels of supervision.

A strong desire to advance one’s professional development is essential to this role.

• 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. Develop knowledge of how to conduct 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. Develop knowledge of Medicare settlement obligations.
• Assess and periodically re-assess the nature and severity of injury or illness. 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 with others on plans of action to mitigate impacts.
• Assess and periodically re-assess claim file reserves adequacy. 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. Emphasis is placed on seeking…