Key Facts

Remote From:

Full time

Mid-level (2-5 years)

English

Hard Skills

Litigation Management Workers' Compensation Claims Reinsurance Vendor Management Compliance Management Litigation Management Care Management Claims And Litigation Management Subrogation Mediation Complaint Investigations Workers' Compensation Claims Online Communication Care Management Stakeholder Communications

Other Skills

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Decision Making
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Non-Verbal Communication
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Analytical Skills
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Strategic Thinking
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Mentorship

Roles & Responsibilities

Bachelor's and/or advanced degree or a minimum of 3 years of Workers' Compensation claims handling experience.
Minimum of 2 years of Workers' Compensation lost time claims handling experience.
West Virginia Workers' Comp Insurance Adjusters license highly preferred.
Intermediate knowledge of law and insurance regulations in various jurisdictions.

Requirements:

Manage coverage analysis, investigation, evaluation, negotiation and disposition of assigned workers' compensation lost time claims, including litigation management and retention of counsel.
Pro-actively manage case resolution, assign medical or other experts as needed, arrange medical examinations, participate in mediations within the limit of settlement authority, and provide timely updates to reinsurers and clients.
Establish and monitor reserves, analyze information to determine extent of loss, and communicate claim status to injured workers, clients, and brokers; provide required reports to AVP, Claims, Underwriting, Reinsurance and Actuarial on significant exposure cases.
Ensure claims are processed within company policies and prescribed authority; effectively manage vendors and expenses; mentor/train new employees as assigned; participate in monthly account renewal meetings as needed.

UPMC

About UPMC

A $23 billion health care provider and insurer, Pittsburgh-based UPMC is inventing new models of patient-centered, cost-effective, accountable care. The largest nongovernmental employer in Pennsylvania, UPMC integrates 92,000 employees, 40 hospitals, 700 doctors’ offices and outpatient sites, and a 4 million-member Insurance Services Division, the largest medical insurer in western Pennsylvania. In the most recent fiscal year, UPMC contributed $1.4 billion in benefits to its communities, including more care to the region’s most vulnerable citizens than any other health care institution, and paid more than $800 million in federal, state, and local taxes. Working in close collaboration with the University of Pittsburgh Schools of the Health Sciences, UPMC shares its clinical, managerial, and technological skills worldwide through its innovation and commercialization arm, UPMC Enterprises, and through UPMC International. U.S. News & World Report consistently ranks UPMC Presbyterian Shadyside among the nation’s best hospitals in many specialties and ranks UPMC Children’s Hospital of Pittsburgh on its Honor Roll of America’s Best Children’s Hospitals. For more information, go to UPMC.com.

Company type: XLarge

Founded: 2018

Company size: 10001

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Job description

UPMC WorkPartners is hiring a full-time Workers Comp Lost Time Claims Specialist II! This role will predominantly work remotely, Monday - Friday daylight hours. The ideal candidate for this position holds a West Virginia Workers Comp Adjuster license.

The UPMC WorkPartners Workers Compensation Lost Time Claims Specialist II reports to the Workers Compensation Claims Supervisor. The Lost Time Claims Specialist II is responsible for coverage analysis, investigation, evaluation, negotiation and disposition of assigned claims for the WorkPartners Workers Compensation business unit. The Lost Time Claims Specialist II will apply litigation management skills to aggressively manage litigation activities, budgets and claim outcomes while considering the overall impact to the customer and company. The Lost Time Claims Specialist II will also ensure claims are processed within company policies, procedures, and within individual's prescribed authority within established best practices and performance standards. The Lost Time Claims Specialist II should possess strategic thought process skills to effectively and efficiently manage loss exposures.

Responsibilities:

Assign medical or other experts to case and arrange for medical examinations when necessary.
Develop lost time claim disposition skills under limited direction of supervisor.
Pro-actively manages the case resolution process. May participate in mediations within limit of settlement authority.
Ensure proper referrals and timely updates to appropriate Reinsurer(s).
Actively participate in claim reviews with clients.
Timely analyze information in order to evaluate assigned claims to determine the extent of loss.
Manage the litigation process through the retention of counsel. Adheres to the line of business litigation guidelines to include budget, bill review and payment under limited direction of supervisor.
Communicate claim status with the injured worker, clients, and broker as needed.
Effectively evaluate, negotiate and resolve claims within delegated authority utilizing the appropriate denials or releases.
Establish appropriate reserves and review on a regular basis to ensure adequacy. Make recommendations to set reserves at appropriate level for claims outside of authority level.
Investigate the claims through telephone, written correspondence, and/or personal contact with claimants, attorneys, clients, witnesses and others having pertinent information.
Provide required reports to AVP, Claims, Underwriting, Reinsurance and Actuarial on significant exposure cases.
Appropriate state licensing to be obtained for assigned jurisdictions.
Effectively evaluate and resolve coverage issues for all Workers' Compensation claim types.
Effectively and efficiently manage vendors and expenses.
Participate in monthly account renewal meetings as needed.
Mentoring and training new employees as appropriately assigned by management.
Bachelors and/or advanced degree or a minimum of 3 years of Workers Compensation claims handling experience.
Minimum of 2 years of Workers Compensation lost time claims handling experience.
West Virginia Workers Comp Insurance Adjusters license highly preferred.
Experience with PA workers compensation is a bonus.
Intermediate knowledge of law and insurance regulations in various jurisdictions.
Demonstrated strong verbal and written communications skills.
Demonstrated strong analytical and decision making skills.
Intermediate knowledge of claims handling concepts, practices and techniques, to include but not limited to coverage issues, litigation management, and product line knowledge.
Previous experience with the reserving and adjudication of the following: Workers' compensation lost time claims, Workers' compensation claim investigations (including subrogation) and compensability decisions.