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UPMC Health Plan and WorkPartners is hiring a full-time Lost Time Claims Specialist I. This role will predominantly work remotely.

The UPMC WorkPartners Workers Compensation Lost Time Claims Specialist I reports to the Workers Compensation Claims Supervisor. The Lost Time Claims Specialist I 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 I 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 I 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 I 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