ESIS Senior Claims Specialist, WC

Under the direction of the Claims Team Leader, the Claims Representative investigates and resolves claims promptly, equitably, and in accordance with established best practices.

Major Duties & Responsibilities

Duties may include, but are not limited to:

• Receive and review new claim assignments.
• Analyze claim and policy information to provide background for investigations and determine the extent of policy obligations.
• Contact, interview, and obtain statements (recorded or in person) from insureds, claimants, witnesses, physicians, attorneys, police officers, and other relevant parties to gather necessary claim information.
• Arrange for surveys and engage experts as appropriate.
• Evaluate facts obtained during investigations to determine liability and the company’s obligations under the policy contract.
• Prepare reports on investigations, settlements, denials, and evaluations of involved parties.
• Set reserves within authority limits and recommend reserve changes to the Team Leader as needed.
• Review claim progress and status with the Team Leader, discussing challenges and recommending solutions.
• Manage litigation files in a timely and appropriate manner.
• Assist the Team Leader in developing methods and improvements for claim handling.
• Settle claims promptly and equitably.
• Obtain releases, proofs of loss, or compensation agreements and issue company payments for claims and related expenses.
• Inform claimants, insureds, agents, or attorneys of claim denials when applicable.
• Assist the Team Leader and company attorneys in preparing cases for trial, including arranging witness attendance and taking statements, while continuing efforts to resolve claims before trial.
• Refer claims to subrogation when appropriate.
• Participate in claim file reviews and audits with customers, insureds, and brokers as needed.
• Administer benefits in a timely and appropriate manner, maintaining control of the claim resolution process to minimize current and future exposure.
• Establish and maintain strong relationships with customers, agents, underwriters, and experts.

Depending on the line of business, additional duties may include:

• Maintaining system logs.
• Investigating compensability and benefit entitlement.
• Reviewing and approving medical bill payments or forwarding for external review as necessary.
• Managing vocational rehabilitation.

Scope Information

This position reports directly to a Claims Team Leader or another member of the claims management team.

• Four-year college degree or equivalent work experience; advanced degrees (such as MBA) are valued.
• High level of technical knowledge and competence in workers’ compensation claims, demonstrated by at least five years of claims handling experience at ESIS or a similar organization. Experience in Texas, Tennessee, and Arizona is preferred.
• Thorough understanding of workers’ compensation products, services, coverages, and applicable legal principles.
• Knowledge of workers’ compensation cost containment programs and proven account management skills.
• Insurance designations such as Associate in Claims (AIC), Associate in Risk Management (ARM), AICPCU, or similar are preferred.
• Ability to plan, organize, and implement general business and people management practices, supported by completion of management and technical programs, business or legal coursework, or equivalent practical experience.
• Effective communication and interpersonal skills, with the ability to interact with colleagues at all levels, attorneys, producers, and accounts.
• Understanding of team-building principles and their application to ongoing and planned activities.
• Ability to evaluate the effectiveness of programs and procedures, incorporate improvements, and facilitate group activities.
• Demonstrated evaluative thinking, including the ability to seek out and consider multiple sources of data to form conclusions and determine actions.
• Evidence of personal effectiveness through confidence, credibility, and commitment to established strategies and values.
• Demonstrated creativity and self-motivation in claim handling and related functions.
• Ability to i