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Requisition Number: 9631
Job Title: Claims Specialist II
Area of Interest: Insurance
Department: TPA and Claims Services - 843
Location: U-Building
Position Type: Full Time
Job Description: Overview:

To analyze assigned workers' compensation claims to determine benefits due; to ensure ongoing adjudication of claims within company standards and industry best practices; and to manage subrogation of claims and negotiate settlements.

Key Responsibilities

  • Review and analyze claim reports and prepare for file make-up.
  • Set initial reserves.
  • Diary for WCB administrative notification requirements (on-time payment, C-7, etc.).
  • Conduct investigation on each reported claim to the extent deemed necessary.  If required, assign for field investigation.
  • Review and evaluate medical reports.
  • Determine compensability and take appropriate action to include filing of necessary forms.
  • Arrange for timely payment of indemnity and medical bills.
  • Follow through on returning the injured workers back to full duties, or modified work, as soon as possible.  When necessary, assign nurse case managers and rehabilitation specialists.
  • Arrange for independent medical examinations when appropriate.
  • Continue to monitor reserves regarding updating as circumstances change.
  • Identify and investigate Section 15-8 possibilities, as well as other areas of limiting the employer's liability such as Section 25-a, Loss Transfer, and other avenues of subrogation.
  • Prepare claims for pre-hearing conferences, hearings and conciliations as scheduled.
  • Ensure that awards, as directed by the Workers' Compensation Board, are paid in a timely fashion following the issuance of a notice of decision.
  • Monitor pension cases and periodic claimant activity checks.
  • Monitor periodic filing of 15-8, 14-6, supplemental benefits, excess insurance and loss transfer reimbursement requests.
  • Document all actions through establishing claim files in accordance with policy and procedural guidelines established by claims management.
  • Settlement dollar authority is $50,000.
  • Bring problematic issues or concerns to the attention of the Claim Manager for further review and discussion.
  • Train and work closely with the claim assistant in order that we can efficiently and effectively perform the services per our contract with the client and meet the rules, regulations and requirements of the Workers' Compensation Board.
  • Close claim files when appropriate so that this is reflected in our loss reporting to our client.
  • Continue to develop one's technical abilities and proficiency through ongoing self-study, approved educational programs, attending in-house and outside seminars, etc.
  • Must adhere to pertinent laws, regulations, First Niagara's Compliance Policy and external compliance requirements.
Requirements: Minimum Qualifications
  • College education preferred or equivalent experience
  • Minimum 5 years workers' compensation claims experience
  • Excellent oral and written communication skills
  • Strong organizational skills
  • Ability to work in a team environment
  • Ability to meet or exceed FNRM performance competencies
State: New York
City: Buffalo
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