Workers Comp- Claims Specialist (I/II/ Sr.)

NJM is seeking a Workers’ Compensation (WC) Claims Specialist (I/II/Sr.). This is a full-time position and offers a hybrid schedule after training with a required Tuesday, Thursday and another day in our West Trenton office. The WC Claims Specialist will be responsible for contacting all parties involved in the claim, gathering, and securing all necessary information to effectively evaluate the claim, and outlining and recommending an action plan to manage the claim. The WC Claims Specialist will work with and communicate to all internal and external stakeholders, including:  NJM policyholders, injured workers, medical providers, the NJM Medical Claims Services Department, the NJM Special Investigation Unit, the NJM WC Legal Staff, and other departments within NJM, as well as outside defense counsel and vendors. 

At NJM, our WC Claims Department empowers our employees to focus on delivering guidance and empathy to our customers because the claims experience is both emotional and memorable.  As a department driven by service and customer advocacy, we are committed to providing transparent, empathetic guidance and collaborative engagement during the life of a claim. The WC Claims Department takes pride in being a key component in the growth and success of our policyholders’ business operations.

To meet these expectations, WC Claims Specialists are supported by a dedicated call center who can field calls for them and other specialized units who are responsible for setting reserves, making permanency payments, and following through on subrogation so they can dedicate the time needed to manage claims. Many of our staff are long tenured with a focus on building relationships, not only with our customers, but with each other providing for a positive and nurturing work environment.

Hours: Monday to Friday 8:00AM- 4:15PM (Hours can vary depending on start time).

Responsibilities:

• Ensure quality management of claims in accordance with claims best practices and company guidelines, and timely, accurate documentation of claim activity
• Provide a high level of customer service that promotes injured worker advocacy-based principles to improve outcomes for all parties 
• Determine compensability and coverage issues by gathering medical and factual evidence
• Administer the delivery of timely, appropriate, and accurate benefits
• Evaluate the claim for potential fraud indicators and escalates the file to SIU, as appropriate
• Recognize and investigate subrogation opportunity and refer to NJM subrogation staff for recovery of third-party funds
• Initiate and provide excellent communication with all stakeholders (injured workers, providers, attorneys, brokers, clients, etc.) professionally and proactively with a customer-centric approach
• Apply critical thinking skills to evaluate and mitigate exposures, and establish and implement a proactive strategic plan of action
• Assign and refer claim petitions to Counsel, and work to resolve the claim within given authority
• Build rapport with policyholders, conduct on-site investigations when necessary, and educate policyholders on NJM procedures, policies, and claim practices
• Prepare for Claim Reviews; attend and participate as needed with the Claims Team and Supervisor
• Participate in in-house and outside training programs to keep current on relevant issues/topics
• Recommend process improvement where applicable to best improve the department efficiency, work product, and service commitment to interested parties
• Demonstrate a commitment to NJM’s Code of Business Conduct and Ethics, and apply knowledge of compliance policies and procedures, standards, and laws applicable to job responsibilities in the performance of work

Required Qualifications and Experience:

• Level I- 1-3 years’ experience as a Workers' Comp Claim Representative, or comparable knowledge and experience with various aspects of claims handling and/or process including knowledge of medical terminology and WC regulations for PA, CT, MD and/or DE claims.
• Level II- 3-5 years’ experience as a Workers' Comp Claim Representative, or comparable knowledge and experience with various aspects of claims handling and/or process including strong knowledge of  medical terminology and WC regulations for PA, CT, MD and/or DE claims.
• Sr Level – 5+ years’ experience as a Workers' Comp Claim Representative, or comparable knowledge and experience with various aspects of claims handling and/or process including advanced knowledge of medical terminology and WC regulations for PA, CT, MD and/or DE claims.
• Knowledge of and/or experience working with liens and Medicare Set-Asides to secure full and final settlements
• Customer service oriented with strong written and oral communication skills
• Strong interpersonal skills with ability to work both in a team and independently
• Demonstrated organizational skills, and use of sound decision-making capabilities
• Working knowledge utilizing an automated claim processing system and Microsoft Office tools including Word and Outlook
• Licensed in CT and/or DE to adjust WC claims or have the ability to obtain these licenses within 90 days.
• Ability to travel for business purposes, approximately less than 10%
• High school diploma or GED required

Preferred:

• Associate or bachelor’s degree
• AIC/CPCU or other applicable insurance designations
• Experience using Guidewire Claim Center, OnBase and additional Microsoft Office tools including Teams, Excel and PowerPoint

Salary: The position can be filled at a I, II, or Sr. level. Salary is commensurate with experience and credentials.

• Level I starting rate is $57,286.45+ annually based on experience and credentials
• Level II starting rate is $65,890.50+ annually based on experience and credentials
• Sr Level starting rate is $79,129.05+ annually based on experience and credentials

Benefits Offered:

• Medical Insurance (Blue Cross Blue Shield)
• Dental Insurance (Delta Dental)
• Vision (Delta Vision/ VSP)
• Flexible Spending Account
• Discounts on NJM auto insurance
• Tuition reimbursement
• Life insurance
• Plus, additional company discounts for items like travel, service, car rental and more!

Compensation: Salary is commensurate with experience and credentials.