Claims Specialist I, Workers Compensation

If you’re passionate about helping people protect what matters most to them, as well as innovating and simplifying processes and operations to provide the best customer value, then Nationwide’s Property and Casualty team could be the place for you! At Nationwide®, “on your side” goes beyond just words. Our customers are at the center of everything we do and we’re looking for associates who are passionate about delivering extraordinary care.

Territory: The location of this position is flexible and open to virtual and/or remote based applicants.  

Job Description Summary

Do you have a strong desire to provide prompt, courteous and fair service to customers? Are you a skilled investigator, negotiator and communicator? If you thrive in an environment where you can problem-solve workers’ compensation claims resolution, while following processes that provide fair resolution, customer satisfaction and cost management, then we want to hear from you!

As a Claims Specialist, you’ll investigate medical and/or loss-of-time workers’ compensation claims with limited exposures from multiple states to determine compensability, entitled benefits, and average weekly wage and benefit rate according to the applicable state workers’ compensation statute. We’ll count on you to promote and provide exemplary customer service. Keys to success will be your ability to establish timely and appropriate case reserves in keeping with best practices and managing claims to appropriate resolution. You’ll also communicate frequently with customers, injured workers and medical providers.

Job Description

Key Responsibilities:

• Provides appropriate notices to policyholders and injured employees per the applicable state workers’ compensation statute and obtains appropriate forms and documentation to verify employee/employer relationships and average weekly wage. Completes and files appropriate first and/or second notice of injury as required by individual state workers compensation statute and electronic data interchange reporting regulations.

• Employs appropriate claims management techniques and direct intervention (e.g., independent medical examinations, referral for rehabilitation, utilization review, etc.) to manage each claim. Maintains contact with policyholders and injured worker and pursues return to work initiatives. Utilizes effective Telephonic Nurse Case Manager or Field Nurse Case Management services to assist with managing medical care and return to work activities. Consults with internal Claims Medical Specialist for future care needs and issues of life expectancy. Evaluates exposures, manages ongoing case reserves in alignment with Best Practices and negotiates settlements as appropriate. Documents significant activity and decision in each claim via on-line claim system.

• Evaluates all pertinent information and works in conjunction with claimant/client to pursue most appropriate claims resolution. Promptly and effectively handles all assigned claims with moderate direction and oversight. Makes decisions within delegated authority as outlined in company policies and procedures. Adheres to high standards of professional conduct consistent with the delivery of superior service.

• Manages litigated claim issues according to best claims practices. Obtains appropriate litigation budgets and develops appropriate power of attorney in partnership with counsel and manages litigation expenses of Nationwide Trial Division or approved outside counsel. Assists or prepares files for lawsuit, trial, or subrogation. (Property/Material Damage/Casualty).

• Fully Investigates and pursues third-party recoveries and any applicable deductibles. May utilize the services of Nationwide recovery unit, and/or partner with designated outside counsel/trial division, or by giving notice of lien to plaintiff counsel handling third party litigation. Claim Zone Field assist referrals and/or outside consulting expert may be utilized to gather, obtain and secure critical information.

• Partners with Special Investigative Unit and Subrogation to identify fraud and subrogation opportunities.

• Maintains and develops current knowledge of: assigned insurance lines; court decisions which may impact the claims function; current guidelines in the claims function; and policy changes and modifications. This may require attendance at various seminars or training sessions.

• Completes state and other regulatory reports/forms to include EDI forms as required by each State Workers’ Compensation Statute or State Regulatory Rules.

• Reviews files for Medicare reporting obligations and submits appropriate Medicare query, Ongoing responsibility for Medicals (ORM) and Total Payment Obligation to claimant (TPOC) reports. May handle claims involving MSA's at time of settlement.

• Delivers a positive customer service experience to all internal, external, current and prospective Nationwide customers. Initiates and conducts follow-ups via proficient use of claims systems and related business systems.

• May periodically conduct customer/account visits to review reserves and discuss status of significant claims. May also present educational workshops to client personnel.

May perform other responsibilities as assigned.

Reporting Relationships: Reports to Supervisor/Manager; no direct reports.

Typical Skills and Experiences:

Education: Undergraduate degree or equivalent experience preferred.

License/Certification/Designation: State licensing where required. Successful completion of required claims certification schools/classes.

Experience: One to three years of experience in workers’ compensation claims.

Knowledge, Abilities and Skills: General knowledge of insurance theory and practices, insurance contracts and their application. Familiarity with claims processing and claims best practices and procedures preferred. Proven knowledge of insurance contracts, medical terminology, workers compensation and the legal aspects of court procedures affecting legal liability for all lines of insurance. Knowledge of claims systems. Ability to meet customer needs and provide exemplary service by informing customers of the claims process and ensuring a positive customer experience. Analytical skills necessary to make decisions/resolve conflicts such as application of coverage's to submitted claims, application of laws of jurisdiction to investigation facts, application of policy exclusions and exceptions and direct repair shop claims management. Ability to work in a fast paced, collaborative environment. Possesses organizational skills to effectively prioritize and manage increased workloads. Demonstrated communication skills for contact and/or negotiations with policyholders, claimants, repair persons, attorneys, agents and the public in general. Ability to efficiently operate personal computer and software for claims-related and other business applications.

Other criteria, including leadership skills, competencies and experiences may take precedence.

Staffing exceptions to the above must be approved by the hiring manager’s leader and HR Business Partner.

Values: Regularly and consistently demonstrates the Nationwide Values.

Job Conditions:

Overtime Eligibility: Exempt (Not Eligible)

Working Conditions: Normal office environment. May require ability to sit and use telephone and personal computer for extended periods of time. Must be willing to work irregular hours and to travel with possible overnight requirements. Must be available to work catastrophes (CAT) requiring travel to CAT site with multiple on-site responsibilities and/or for extended periods of time. Extended and/or non-standard hours as required.

ADA: The above statements cover what are generally believed to be principal and essential functions of this job. Specific circumstances may allow or require some people assigned to the job to perform a somewhat different combination of duties.

Credit/Background Check: Due to the fiduciary accountabilities within this job, a valid credit check and/or background check will be required as part of the selection process.

We currently anticipate accepting applications until 01/02/2025. However, we encourage early submissions, as the posting may close sooner if a strong candidate slate is identified before the deadline.

Benefits

We have an array of benefits to fit your needs, including: medical/dental/vision, life insurance, short and long term disability coverage, paid time off with newly hired associates receiving a minimum of 18 days paid time off each full calendar year pro-rated quarterly based on hire date, nine paid holidays, 8 hours of Lifetime paid time off, 8 hours of Unity Day paid time off, 401(k) with company match, company-paid pension plan, business casual attire, and more. To learn more about the benefits we offer, click here.

Nationwide is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive culture where everyone feels challenged, appreciated, respected and engaged. Nationwide prohibits discrimination and harassment and affords equal employment opportunities to employees and applicants without regard to any characteristic (or classification) protected by applicable law.

This position could be filled within any of the lower 48 U.S. states.#claimsSmoke-Free Iowa Statement: Nationwide Mutual Insurance Company, its affiliates and subsidiaries comply with the Iowa Smokefree Air Act. Smoking is prohibited in all enclosed areas on or around company premises as well as company issued vehicles. The company offers designated smoking areas in which smoking is permitted at each individual location. The Act prohibits retaliation for reporting complaints or violations. For more information on the Iowa Smokefree Air Act, individuals may contact the Smokefree Air Act Helpline at 888-944-2247.
For NY residents please review the following state law information: Notice of Employee Rights, Protections, and Obligations LS740 (ny.gov) https://dol.ny.gov/system/files/documents/2022/02/ls740_1.pdfNationwide pays on a geographic-specific salary structure and placement within the actual starting salary range for this position will be determined by a number of factors including the skills, education, training, credentials and experience of the candidate; the scope, complexity and location of the role as well as the cost of labor in the market; and other conditions of employment. If a Sales job, Sales Incentives, based on performance goals are possible in addition to this range.The national salary range for Claims Specialist I, Workers Compensation : $48,900.00-$101,100.00The expected starting salary range for Claims Specialist I, Workers Compensation : $54,300.00 - $81,500.00