UPMC's Health Plan is hiring a Lost Time Claims Specialist I for its Workpartners team.
This is a remote position that requires travel into the Downtown Pittsburgh location several times a year.
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The UPMC Workpartners Workers' Compensation Lost Time Claims Specialist 1 reports to the Workers' Compensation Claims Supervisor. The Lost Time Claims Specialist 1 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 1 will develop 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 1 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 1 should possess strategic thought process skills to effectively and efficiently manage loss exposures.Responsibilities:
- 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.
- Effectively evaluate and resolve coverage issues for all Workers' Compensation claim types.
- Pro-actively manages the case resolution process. May participate in mediations within limit of settlement authority under supervision.
- Provide required reports to AVP, Claims, Underwriting, Reinsurance and Actuarial on significant exposure cases.
- Appropriate state licensing to be obtained for assigned jurisdictions.
- Actively participate in claim reviews with clients.
- Effectively and efficiently manage vendors and expenses.
- Assign medical or other experts to case and arrange for medical examinations when necessary.
- Timely analyze information in order to evaluate assigned claims to determine the extent of loss.
- 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.
- Ensure proper referrals and timely updates to appropriate Reinsurer(s) if applicable.
- Investigate the claims through telephone, written correspondence, and/or personal contact with claimants, attorneys, clients, witnesses and others having pertinent information.
- Manage the litigation process through the retention of counsel. Adheres to the line of business litigation guidelines to include budget, bill review and payment.
- Develop lost time claim disposition skills under the direction of supervisor.
- Bachelors and/or advanced degree or a minimum of 2 years of Workers Compensation claims handling experience.
- A minimum of 1 year of Workers' Compensation lost time claims handling experience or 18 months of Workers' Compensation medical only claims handling experience.
- Basic 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, and product line knowledge.
- Previous experience with the reserving and adjudication of the following: Workers' compensation medical only claims Workers' compensation claim investigations and compensability decisions.
Licensure, Certifications, and Clearances: - Act 34
UPMC is an Equal Opportunity Employer/Disability/Veteran
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