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New Mexico Mutual · 1 day ago

Claims Specialist

Albuquerque,NM,US

Full-time

Onsite

Senior Level

5+ years exp

New Mexico Mutual is a company that specializes in workers' compensation insurance. They are seeking a Claims Specialist to provide expert claim handling services, evaluate complex claims, and ensure compliance with applicable laws and corporate policies.

Financial ServicesInsuranceService Industry

Responsibilities

Evaluate, analyze and determine compensability, causation, offsets and exposures of serious and complex workers compensation insurance claims in accordance with applicable law, corporate policy, best practice and prescribed authorities

Verify claim information including but not limited to: documentation of the claim history; taking recorded statements from workers and witnesses, identify subrogation opportunities, coordination of medical care

Document all activities in the claim management system. Responsible for outside legal counsel assignments, RTW strategies with policyholders, implement medical case management strategies with nurse case managers and all other expert assignments

Upon determination of compensability: Set and monitor reserves according to company policies and the worker’s injury, issue benefit checks in accordance to statutory requirements, and demonstrate proficiency in the application of state statutes, related case law and to interpret and comply with company claims standards, policies and procedures. Must have above-average knowledge, understanding and ability to apply case law to claim handling practices

Ensure the timely and accurate statutory/benefit payments within the established time frames and guidelines

Prepare and participate in mediation conferences and other authorized legal or regulatory proceedings before the regulatory agencies and courts of law

Maintain a diary on all open claims. Document all relevant information to provide a clear history of events and a proper audit trail. Set review dates based on claim complexity or standard review criteria

Assess and report claims litigation for significant financial exposure, case law precedent or reputation risk

Identify and recommend claims with potential for full and final settlement and negotiate and/or coordinate with authorized outside legal counsel in full and final settlements

Analyze assigned claims to identify trends and opportunities for improvement of policies, procedures and controls, and prepare related reports

Mentor junior adjusters and provide support to Claims Managers as directed

Detect and report reasonable suspicions of insurance fraud by claimants, medical or legal providers, policyholders or other individuals related to claims

Maintain claim records in compliance with applicable law, corporate policies and retention schedules

Qualification

Workers' compensation claimsClaims handling expertiseState adjuster's licenseLegal compliance knowledgeNegotiation skillsEffective communicationCollaborative skillsPositive attitude

Required

Bachelor's Degree from an accredited college or university

5+ years of serious workers' compensation claims experience

10+ claims handling experience

Demonstrated proficiency in related professional certifications preferred

State required adjuster's license

Adhere to values and mission by demonstrating Service Excellence, Trust, Ownership, One team and Boldness in thought and action

Develops and maintains positive working relationships with team members, customers, co-workers and management by demonstrating effective communication and collaborative skills