WC Claims Specialist II

Job Description

Job DescriptionDescriptionOur StoryImagine being part of a team that’s not just shaping the future but actively driving it. At Davies North America, we’re at the forefront of innovation and excellence, blending cutting-edge technology with top-tier professional services. As a vital part of the global Davies Group, we help businesses navigate risk, optimize operations, and spearhead transformation in the insurance and regulated sectors.

USIS, a part of the Claims Solutions division of Davies North America, is looking for an experienced Workers’ Compensation Claims Specialist, responsible for the investigation, evaluation, disposition, and settlement of Workers’ Compensation claims for self-insured and public entity accounts, including complex and high exposure claims, with minimal supervision. This includes the investigation, determination and evaluation of coverage, liability and damages, and the setting of proper reserves. Requires independent decision making and a high level of discretion and judgment in claim handling functions on behalf of clients for claims service business operations, ensuring excellent customer relationships and quality customer service. Reporting to the WC Claims Supervisor, you will be responsible for the investigation, evaluation, disposition and settlement of Workers’ Compensation claims for self-insured and public entity accounts, including complex and high exposure claims, with minimal supervision. This includes the investigation, determination and evaluation of coverage, liability and damages, and the setting of proper reserves. Requires independent decision making and a high level of discretion and judgment in claim handling functions on behalf of clients for claims service business operations, ensuring excellent customer relationships and quality customer service. To be successful in this role, you need to have experience in a claims environment handling lost time claims, including litigated files.
Key Responsibilities

• Analyze the claim exposure to determine the proper course of action and to appropriately settle or close the claim in accordance with state, company and client policy and procedure.
• Build and maintain rapport with client contacts to ensure retention; perform in manner to meet/exceed client expectations, following policy and procedure per client.
• Manage and direct the claim file including determination of indemnity, calculate loss of income; whether medical is related and appropriate; evaluate treatment plan, testing, surgery, surveillance, attorney involvement, return-to-work, light duty; appropriate calculation and timely payment of all benefits.
• Handle legal aspects of the file in negotiation of settlement; develop litigation/defense strategies with attorneys assigned to the claim file. Handle depositions, mediations, and hearings.
• Maintain system diary, keeping all files current according to company standards and State timeframes, ensuring no late payments or fines.
• Evaluate files for reserve potential and for settlement (effective knowledge of MSAs and structured annuities).
• Handle claims consistent with client, state and company policy and procedure, and in accordance with any statutory, regulatory and ethics requirements.
• Document and communicate all claim activity timely and effectively and in a manner which supports the outcome of the claim file; develop and maintain a progressive plan of action.
• Follow protocol for file management including proper case note documentation, email/fax handling, naming imaged documents appropriately, updating required system fields and templates as required.
• Interact extensively with various parties involved in the claim process.
• Manage EDI requirements per state and company protocol in a timely and appropriate manner.
• Identify and pursue SDF, subrogation, fraud, vocational/field case management involvement, as necessary
• Comply with excess carriers’ limits and reporting requirements.
• Properly handle status reports/claim reviews with clients; travel as required.
• Maintain current knowledge of law and statute, maintain CEUs and license in current status related to state in which handling claims.
• Exhibit company values of We are Dynamic, We are Innovative, We are Connected, and We Succeed Together
• Perform other duties as assigned.

Skills, knowledge & expertise

• Active Adjuster license (FL 5-24, 5-20 or 6-20).
• A minimum of three years of Florida claims-related experience with a consistent high level of performance and achievement.
• Must have US work rights.
• Must have a valid Driver’s License; some travel required
• To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions.
• Extensive knowledge of accepted industry standards and practices including case law.
• Ability to successfully negotiate the settlement and disposition of claims, including the ability to interpret related documentation.
• Maintain knowledge of current trends, standards and law changes.
• Ability to effectively operate a personal computer and related claims and business software. Technically competent with systems. Familiarity with “paperless” work environment helpful.
• Must be self-directed and able to work independently.
• Ability to effectively present status updates in claims meetings with clients, etc.
• Good communication skills, both oral and written; good customer service skills.
• Assertive self-starter with excellent organizational skills. Team player. Good attendance.

BenefitsBenefitsAt Davies North America, we are dedicated to supporting the well-being and future of our qualifying employees. Our comprehensive benefits package includes:

• Medical, dental, and vision plans to ensure your health and that of your family.
• A 401k plan with employer matching to help you build a secure financial future.
• Our time-off policies, including Discretionary Time Off for exempt employees and Paid Time Off (PTO) package for non-exempt employees, reflect our commitment to promoting a healthy work environment.
• Paid holidays.
• Life insurance and both short-term and long-term disability plans, providing essential financial protection for you and your loved ones.

Diversity and InclusionDavies is dedicated to fostering a diverse and inclusive workplace that embraces a wide range of perspectives and experiences. We believe that diversity of thought is essential for innovation and creativity, and we actively promote an environment where all voices are valued and heard.