Lost Time Claims Specialist II - Hybrid

UPMC Health Plan and WorkPartners are seeking a full-time Lost Time Claims Specialist II to join our Workers’ Compensation Case Management team! In this role, you will provide support to a dedicated and exclusively assigned external client. This hybrid position will initially require working onsite at the Heinz 57 Center in downtown Pittsburgh three days per week. After successful completion of training, onsite presence will be reduced to one day per week. Please note that work arrangements are subject to change.

The Lost Time Claims Specialist II manages coverage analysis, investigation, evaluation, negotiation, and resolution of assigned Workers’ Compensation claims. The role includes actively managing litigation, and driving optimal claim outcomes while considering customer and company impact. The specialist ensures all claims comply with policies, procedures, authority limits, and best practices, and applies strategic thinking to effectively manage loss exposure.

Responsibilities:
 

•  Investigate the claims through telephone, written correspondence, and/or personal contact with claimants, attorneys, clients, witnesses and others having pertinent information.
• Communicate claim status with the injured worker, clients, and broker as needed.

• Provide required reports to AVP, Claims, Underwriting, Reinsurance and Actuarial on significant exposure cases as requested.

   

• Effectively evaluate and resolve coverage issues for all Workers' Compensation claim types.

• Effectively and efficiently manage vendors and expenses.

   

• Mentoring and training new employees as appropriately assigned by management.
• Timely analyze information in order to evaluate assigned claims to determine the extent of loss.
• Manage the litigation process through the retention of counsel. Adheres to the line of business litigation guidelines to include budget, bill review and payment under limited direction of supervisor.
• Effectively evaluate, negotiate and resolve claims within delegated authority utilizing the appropriate denials or releases as directed.
• 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.
• Assign medical or other experts to case and arrange for medical examinations when necessary.
• Develop lost time claim disposition skills under limited direction of supervisor.
• Pro-actively manages the case resolution process. May participate in mediations within limit of settlement authority.
• Ensure proper referrals and timely updates to appropriate Reinsurer(s).
   

• Bachelors and/or advanced degree or a minimum of 3 years of Workers Compensation claims handling experience. 
• Minimum of 2 years of Workers Compensation lost time claims handling experience. 
• Technical aptitude preferred as this role will include working within UPMC and external client systems. 
• Prior experience with collective bargaining is a bonus. 
• Intermediate 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, litigation management, and product line knowledge. 
• Previous experience with the reserving and adjudication of the following: Workers' compensation lost time claims, Workers' compensation claim investigations (including subrogation) and compensability decisions. 
  
  Licensure, Certifications, and Clearances:
  
  UPMC is an Equal Opportunity Employer/Disability/Veteran