Workers' Compensation Claims Specialist

At EMC, we’re all about working together to make an impact. As part of our team, you’ll have the opportunity to grow, contribute, and gain experience that matters. We strive to be caring leaders, close partners, and responsive experts—always supporting each other to do our best work. Join us, and let’s improve lives together.

**This role can be performed remotely anywhere in the US, with preference for those who have either Texas or Iowa jurisdiction experience**

Essential Functions:

• Reviews claim notices, lawsuits, contracts, and policies to verify coverage and compensability

• Initiates timely contact with customers and thoroughly explains the claim process

• Obtains statements from insureds, claimants, witnesses, and all other pertinent parties

• Evaluate reassigned files as they reach the most complex level to identify any missing investigative information

• Documents claims activities, reserve analysis, summaries of reports in the claim system

• Completes thorough analysis of pertinent facts and sets and maintains timely, adequate reserves in accordance with the company reserving philosophy and methodology to cover company exposure

• Re-evaluates claim as new facts are identified through the investigation and medical treatment updates

• Secures all necessary official reports, claim forms, and pertinent documents

• Reviews bills, invoices, and receipts, including legal and litigation related expenses, for accuracy and appropriateness

• Notifies all parties involved that legally require appropriate notice

• Calculates benefits due and pays accordingly in compliance with state jurisdictional statutes

• Coordinates return to work with medical provider, nurse case manager, insured, and injured employee

• Coordinates appropriate medical care, including using appropriate and complex cost containment techniques and resources with catastrophic losses.

• Maintains accurate and timely diaries on all files on an on-going basis

• May assist in reinsurance reporting as needed

• Coordinates Medicare set-aside and lien issues, and documents activity including Medicare (MSP) modules in the claims system

• Identifies coverage concerns and resolves questions regarding additional insureds and contribution claims

• Resolves questions of liability, compensability, and settlement value

• Coordinates independent adjusters, experts, and other vendors and manages their budget and reporting to provide the best outcome

• Recommends and selects appropriate defense counsel based on the nature of suit and complexity of the matter for litigated claims

• Identifies, investigates, and proactively pursues opportunities for recovery

• Handles litigation of severe and complex workers’ compensation claims 

• Collaborates with defense counsel on action plans and litigation strategy to manage litigation expenses and obtain favorable outcomes 

• Drafts independent medical exam (IME), state required letters, and denial letters with supervisor approval when appropriate

• Communicates with insureds, injured workers, and attorneys to negotiate the settlement of claims

• Prepares settlement evaluations, negotiation ranges and target settlement numbers with claimants, insureds, and defense counsel to negotiate when appropriate 

• Attends depositions, hearings, trials, and mediations 

• Prepares settlement documents in collaboration with all relevant parties with consideration of extrinsic information.

• Issues timely settlement payments  

• Investigates Medicare liens and timely resolve in accordance with EMC and Medicare guidelines 

• Manages claim recoveries including subrogation, second injury fund, social security, and Medicare offsets 

• Complies with all state-specific and jurisdictional reporting requirements through all required communication channels and documents actions appropriately

• Submits referrals to Special Investigation, Subrogation, Medical Review Units and Corporate Office Coverage Counsel as appropriate  

• Actively participates in claims roundtables by preparing cases needing group discussion and providing input on cases shared by other claims adjusters

• Serves as a subject matter expert for workers’ compensation claims team members. Assists in handling of claims or suits outside of their jurisdiction

• Provides guidance to team members with technical issues of a claim and answers questions on coverage, compensability, investigations and plans of action

• Prepares risk alerts for Underwriting and Risk Improvement

• Maintains continuing education credits and licenses as required by jurisdiction

Education & Experience:

• Bachelor’s degree or equivalent relevant experience

• Eight years of workers’ compensation claims adjusting experience or related experience

• Attainment of all applicable state licenses within six months of hire

• Relevant insurance designations preferred

Knowledge, Skills & Abilities:

• Superior knowledge of best claims practices used to resolve the most serious and complex workers compensation claims

• Advanced knowledge of the claim function

• Excellent knowledge of insurance contracts, medical terminology and substantive and procedural laws

• Ability to adhere to high standards of professional conduct and code of ethics

• Excellent knowledge of computers and claims systems

• Exceptional organizational and written and verbal communication skills

• Excellent customer service skills

• Superior investigative and problem-solving abilities

• Travel required; a valid driver’s license with an acceptable motor vehicle report per company standards required if driving

The hiring salary range for this position will vary based on geographic location, falling within either of the following:

A hiring range represents a subset of the full salary range. The actual salary will depend on several factors, including relevant education, skills, and experience of an applicant, geographic location, and business needs.

For information relating to the benefits EMC Team Members receive as part of a comprehensive rewards package, please visit www.emcins.com/careers.

Our employment practices are in accordance with the laws that prohibit discrimination due to race, color, creed, sex, sexual orientation, gender identity, genetic information, religion, age, national origin or ancestry, physical or mental disability, medical condition, veteran status, active military status, citizenship status, marital status or any other consideration made unlawful by federal, state, or local laws.

All of our locations are tobacco free including in company vehicles.