Claims Specialist II, Workers Compensation

Claims Specialist

If you're passionate about helping people protect what matters most to them, as well as innovating and simplifying processes and operations to provide the best customer value, then Nationwide's Property and Casualty team could be the place for you! At Nationwide, "on your side" goes beyond just words. Our customers are at the center of everything we do and we're looking for associates who are passionate about delivering extraordinary care. The location of this position is flexible and open to virtual and / or remote based applicants.

Do you have a strong desire to provide prompt, courteous and fair service to customers? Are you a skilled investigator, negotiator and communicator? If you thrive in an environment where you can problem-solve workers' compensation claims resolution, while following processes that provide fair resolution, customer satisfaction and cost management, then we want to hear from you! As a Claims Specialist, you'll investigate and handle medical and / or loss-of-time workers compensation claims from multiple states to determine compensability, entitled benefits, average weekly wage and benefit rate according to applicable state workers' compensation statute. We'll count on you to promote and provide exemplary customer service. Key to success will be your ability to establish timely and appropriate case reserves aligned with Best Practices and manage claims to appropriate resolution. You'll also communicate frequently with customers, injured workers and medical providers.

Key Responsibilities :

• Provides appropriate notices to policyholders and injured employees according to applicable state workers' compensation statute and obtains appropriate forms and documentation to verify employee / employer relationship and average weekly wage. Completes and files appropriate first and second notice of injury as required by individual state workers' compensation statute and electronic data interchange reporting regulations.
• Employs appropriate claims management techniques and direct intervention (e.g., independent medical examinations, referral for rehabilitation, utilization review, etc.) to manage each claim. Maintains contact with policyholders and injured worker and pursues return to work initiatives. Utilizes effective Telephonic Nurse Case Manager or Field Nurse Case Management services to assist with managing medical care and return to work activities. Consults with internal Claims Medical Specialist for future care needs and issues of life expectancy. Evaluates exposures, manages ongoing case reserves in alignment with best practices and negotiates settlements as appropriate. Documents significant activity and decisions in each claim via on-line claim system.
• Evaluates all pertinent information and works in conjunction with claimant / client to pursue most appropriate claims resolution.
• Investigates and pursues third party recoveries and any applicable deductibles. May utilize the services of Nationwide recovery unit, and / or partner with designated outside counsel / trial division, or by giving notice of lien to plaintiff counsel handling third party litigation. Claim Zone Field assist referrals and / or outside consulting expert may be utilized to gather, obtain and secure critical information.
• Manages litigated claim issues in alignment with Best Claims Practices. Obtains appropriate litigation budgets and develops appropriate power of attorney in partnership with counsel. Manages litigation expenses of Nationwide Trial Division or approved outside counsel.
• Manages assigned claims with little to no direction and oversight. Makes decisions within delegated authority as outlined in company policies and procedures. Adheres to high standards of professional conduct consistent with the delivery of superior service.
• Submits severe incident reports, reinsurance reports and other information to home office, claims management, and underwriting.
• Reviews files for Medicare reporting obligations and submits appropriate Medicare query, Ongoing responsibility for Medicals (ORM) and Total Payment Obligation to claimant (TPOC) reports. Responsible for claims involving Medicare Set Aside at time of settlement and which may be funded by a structured settlement.
• Partners with Special Investigative Unit (SIU) and Subrogation to identify fraud and subrogation opportunities.
• Delivers a positive customer service experience to all internal, external, current and prospective Nationwide customers.
• May periodically conduct customer / account visits to review reserves and discuss status of significant claims. May also present educational workshops to client personnel.

Reporting Relationships : Reports to Supervisor / Manager. No direct or indirect reports.

Typical Skills and Experiences :

Education : Undergraduate studies in business administration or related field preferred and / or relevant Workers' Compensation experience.

License / Certification / Designation : State licensing where required. Successful completion of required / applicable claims certification training / classes.

Experience : Three to five years prior experience in workers' compensation claims.

Knowledge, Abilities and Skills : Advanced knowledge of insurance theory and practices, insurance contracts and their application. Familiarity with claims processing and claims best practices and procedures preferred. Proven knowledge of insurance contracts, medical terminology, workers compensation, and the legal aspects of court procedures affecting legal liability for all lines of insurance. Knowledge of claims systems. Excellent customer focus and proven ability to proactively meet customer needs. General knowledge of insurance theory and practices, insurance contracts and their application. Familiarity with claims processing and claims best practices and procedures preferred. Knowledge of insurance contracts, medical terminology, workers compensation, and the legal aspects of court procedures affecting legal liability for all lines of insurance. Knowledge of claims systems. Analytical skills necessary to make decisions and resolve conflict in such areas as application of coverage to submitted claims, application of laws of jurisdiction to investigation facts, application of policy exclusions and exceptions. Ability to establish repair requirements and cost estimates for extensive losses and serves as a subject matter expert on respective claims projects. Proven organizational skills to effectively prioritize increased and more complex workloads. Demonstrates strong but flexible standards to balance the conflicting demands of the position. Excellent written and verbal communication skills necessary to effectively communicate and / or negotiate with policyholders, claimants, attorneys, agents, and general public. Demonstrated leadership capabilities to effectively train, coach, and provide feedback to less experienced associates.

Other criteria, including leadership skills, competencies and experiences may take precedence.

Staffing exceptions to the above must be approved by the hiring manager's leader and HR Business Partner.

Values : Regularly and consistently demonstrates the Nationwide Values.

Job Conditions :

Overtime Eligibility : Exempt (Not Eligible)

Working Conditions : Normal office environment. May require ability to sit and use telephone and personal computer for extended periods of time. Must be willing to work irregular hours and to travel with possible overnight requirements. Must be available to work catastrophes (CAT) requiring travel to CAT site with multiple on-site responsibilities and / or for extended periods of time. Extended and / or non-standard hours as required.

ADA : The above statements cover what are generally believed to be principal and essential functions of this job. Specific circumstances may allow or require some people assigned to the job to perform a somewhat different combination of duties.

Credit / Background Check : Due to the fiduciary accountabilities within this job, a valid credit check and / or background check will be required as part of the selection process.

We currently anticipate accepting applications until 11 / 27 / 2025. However, we encourage early submissions, as the posting may close sooner if a strong candidate slate is identified before the deadline.

We have an array of benefits to fit your needs, including : medical / dental / vision, life insurance, short and long term disability coverage, paid time off with newly hired associates receiving a minimum of 18 days paid time off each full calendar year pro-rated quarterly based on hire date, nine paid holidays, 8 hours of Lifetime paid time off, 8 hours of Unity Day paid time off, 401(k) with company match, company-paid pension plan, business casual attire, and more.

Nationwide is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive culture where everyone feels challenged, appreciated, respected and engaged.