UPMC Health Plan and WorkPartners is hiring a full-time Lost Time Claims Specialist II to join the Workers Comp Claims team. This remote role will work business hours EST Monday - Friday and will primarily support Florida and Georgia claims. The ideal candidate will hold an active Florida and Georgia Workers’ Compensation Adjuster license and have prior experience managing lost time claims in both states.
The Lost Time Claims Specialist 2 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 2 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 2 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 2 should possess strategic thought process skills to effectively and efficiently manage loss exposures.
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. 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. Florida and Georgia Workers Comp Adjusters license strongly preferred. Florida and Georgia lost time claims experience strongly preferred.
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. Licensure, Certifications, and Clearances: UPMC is an Equal Opportunity Employer/Disability/Veteran