Claims Quality Audit Director jobs in Vineland, NJ

Introduction

Overview

NJM’s Workers’ Compensation Claims Team is seeking a Regional Claims Specialist. This is a full-time position and offers a hybrid schedule after training.

The Regional Claims Specialist will be responsible for contacting all parties involved in the claim, gathering, and securing all necessary information to effectively evaluate the claim, and outlining and recommending an action plan to manage the claim. The Regional Claim Specialist will work with and communicate to all internal and external stakeholders, including: NJM policyholders, injured workers, medical providers, the NJM Medical Services Administration Department, the NJM Special Investigation Unit, WC Legal Staff, and other departments within NJM, as well as outside defense counsel and vendors.

This role can be based in NJM’s West Trenton, NJ or Hammonton, NJ office location.

Responsibilities

• Execute strategic and operational goals and objectives of the WCC department and company business goals, guidelines, and programs.
• Recommend process improvement where applicable to best improve the department efficiency, work product, and service commitment to interested parties.
• Manage litigated claims through proactive execution of action plans to resolve claim issues to move cases toward closure and reduce aged inventory.
• Ensure quality management of claims in accordance with claims best practices and company guidelines, and timely, accurate documentation of claim activity.
• Provide a high level of customer service that promotes injured worker advocacy-based principles to maximize return to work motivation and improve outcomes for all parties. 
• Determine compensability and coverage issues that have been placed in litigation by gathering medical and factual evidence.
• Administer the delivery of timely, appropriate, and accurate indemnity and medical benefits.
• Evaluate the claim for potential fraud indicators and escalate the file to SIU, as appropriate.
• Recognize and investigate subrogation opportunities for recovery of third-party funds.
• Initiate and provide excellent communication with all stakeholders (injured workers, providers, attorneys, brokers, clients, etc.) professionally and proactively with a customer-centric approach.
• Apply critical thinking skills to evaluate and mitigate exposures, and establish and implement a proactive strategic plan of action.
• Assign and refer claim petitions to Counsel, and work to resolve the claim within given authority.
• Promptly manage and resolve issues on litigated cases, inclusive of evaluating claim exposure, negotiating, and resolving claims.
• Build rapport with the policyholder, conduct on-site investigations when necessary, and educate the policyholder on NJM legal procedures, policies, and claim practices.
• Prepare for Claim Reviews; attend and participate as needed with the Claims Team and Supervisor.
• Participate in in-house and outside training programs to keep current on relevant issues/topics.
• Demonstrate a commitment to NJM’s Code of Business Conduct and Ethics, and apply knowledge of compliance policies and procedures, standards, and laws applicable to job responsibilities in the performance of work.

Requirements

• Level I- 0-3 years’ experience as a Workers' Comp Claim Representative, or comparable knowledge and experience with various aspects of claims handling and/or process including basic knowledge of WC Law, medical terminology, and utilization of an automatic claims processing system.
• Level II- 3-5 years’ experience as a Workers' Comp Claim Representative, or comparable knowledge and experience with various aspects of claims handling and/or process including strong knowledge of WC Law, medical terminology, and utilization of an automatic claims processing system.
• Sr Level– 5 years’ experience as a Workers' Comp Claim Representative, or comparable knowledge and experience with various aspects of claims handling and/or process including advanced knowledge of WC Law, medical terminology, and utilization of an automatic claims processing system.
• Knowledge of WC regulations and jurisdiction(s) to be able to formulate a Plan of Action to bring claims to resolution.
• Knowledge of and experience working Work with liens and Medicare Set-Asides to secure full and final settlements.
• Customer service oriented with strong written and oral communication skills.
• Strong interpersonal skills with ability to work both in a team and independently.
• Demonstrated organizational skills, and use of sound decision-making capabilities.
• Working knowledge utilizing an automated claim processing system and the Microsoft Office suite of tools (Word, Excel).
• Ability to travel for business purposes, approximately less than 10%.

Preferred:

• Multi-state experience and/or licensing (including NJ, MD, CT, DE, PA and/or NY).
• Associate or Bachelor’s degree.
• AIC/CPCU Designations.

Salary:

• Level I - $54K - $68K annually based on experience and credentials.
• Level II - $62K annually based on experience and credentials.
• Sr Level - $75K annually based on experience and credentials.