Claims Technical Specialist
In the role of the Claims Technical Specialist, you will use your knowledge of WC insurance to provide claim-related technical support to SFM's claims staff in application of policies, procedures, and claim file financial reconciliation. There is a high emphasis on supporting EDI filings, auditing of files, training and working with our IT department to identify system issues. SFM offers a robust benefit package that includes all the perks you need to navigate your work-life journey. SFM believes that our exceptional and motivated employees are our greatest strength, and we are committed to creating the best work environment. This position allows you to use your claims handling experience to improve internal procedures and develop others.
Remote/hybrid work is offered for this role.
Our benefits include:
- Affordable Medical, Dental, Vision Insurance, HSA, FSA
- Flexible hybrid work environment
- Traditional and Roth 401(k) plans with company match
- Company contributions to help pay off student loans
- Monthly home internet allowance
- Free life insurance, STD & LTD
- Opportunities for annual gainshare bonus
- Pet insurance
- Generous PTO
- 9 paid holidays
- Paid parental leave
- Annual company-wide volunteer day
- Discounts on gym memberships, fitness apps and weight loss programs
- Adoption financial assistance
The Claims Technical Specialist will have a focus on the Financial & Regulatory areas for workers' compensation claims. You provide claim-related technical support to staff in application of claims management policies, practices, procedures, and claim file financial reconciliations. And, perform regular internal technical claim reviews to ensure best practices and quality standards. Responsible for state, federal, contractual and reinsurance compliance, reporting and auditing, including but not limited to EDI regulatory reporting. Reconciles financial liability on claims by auditing and working with Information Services in development of software programming to minimize errors and account for corrections. Participates in the development and delivery of claims staff training. This is a hybrid role, so some in office work is needed.
- Manages and troubleshoots claim reporting interfaces-EDI reporting for all jurisdictions, which may include problem-solving in collaboration with the IS Team.
- Ensures SFM is in regulatory compliance by keeping up to date on any changes to federal and state reporting requirements and delivers timely implementation of SFM's system/processes.
- Manages claims reporting and claims management communication with all SFM reinsurers.
- Trains and assists SBU team members on claim regulatory filings.
- Monitors, enhances and corrects individual claim reporting issues for Medicare.
- Manages CMS reporting and conditional payment liens from CMS.
- Ensures compliance with NCCI data reporting.
- Resolves claim accounting issues, by assisting claim representatives with financial audits and working with Finance on recovery issues.
- Participates in the management of permanent total and dependency claims.
- Reconciles financial liability on claims by auditing and working with Information Services, as necessary, to ensure errors are minimized.
- Assures integrity of computer system, including but not limited to data base testing.
- Acts as a resource and provides technical training and development of claims staff.
- Collaborates with Team Leader and assists with developing best practices and operational improvement opportunities. Maintains claim procedures, best practices and resources on intranet relating to financial and regulatory matters.
- Responsible for maintaining prompt action results for applicable jurisdiction, which includes analysis to identifying possible gaps, developing processes or training if improvement is necessary, and regular communication to management regarding status of the same.
- Keeps abreast of mandated rules, procedures and forms. Communicates modifications and recommendations to Team Leader. This may include review and documentation of law, rules and system modifications needed for entry into a new state for claims handling.
- Assists Leader by keeping apprised of emerging trends (legal decisions, penalties, settlements) in workers' compensation for all core jurisdictions, which includes but is not limited to changes to EDI reporting.
- Participates in management, development and delivery of claims software system enhancements and staff training of the same.
- Engages in file reviews for overall performance, prompt initial actions, and compliance with customer contracts, including, but not limited to Assigned Risk Plan contracts.
- Develops and participates in strategizing and decision making on high exposure cases to assist the claims management process, including settlements and evaluation of loss exposure.
- Identifies, develops and implements business solutions to business needs and special projects. This may include a heavy emphasis on technology.
- Supports the maintenance tables in computer system for all core states.
- Provides training to claims staff as directed by the Claims Technical Employee Development team. Maintains appropriate interactions with persons both within the organization and externally.
- Manages claim administrator for non-core states, including acting as liaison between SFM internal and external customers.
- Travel on an as needed basis to meet with policyholders, agents, and claimants and attend applicable industry conferences.
We're looking for:
- Bachelor's degree in business, risk management, insurance or related field; in lieu of a Bachelor's degree, 4 years of suitable work experience is accepted.
- IAIABC Claims EDI Standard knowledge preferred.
- Seven or more years of experience handling workers compensation claims, or similar functions in the property and casualty space.
- Experience in Cognos or other report writing software strongly desired.
- Professional insurance designations relevant to area of expertise preferred.
- Excellent reasoning and decision-making abilities.
- Excellent presentation skills.
- Proven ability to inspire, coach and educate others to follow company protocol and claims best practices.
- Ability to mentor and assist in employee development.
- Proven ability to apply confidentiality and exercise considerable judgment and discretion.
- Highly organized and detail oriented.
- Excellent multitasking skills, and the ability to work in a fast-paced environment with minimal direction.
- Solid technical knowledge of financial procedures and principles which may include a specialty area of the business, such as reinsurance.
- Ability to communicate effectively with a diverse group of people and manage difficult situations with tact
- Strong math skills.
- Strong customer service and interpersonal skills and ability to work well within a team environment.
- Excellent analytical research skills.
- Excellent verbal, written and presentation skills.
- Proficient in MS Office software applications (Excel, Word, etc.).
- Travel as needed.
Regular attendance is required. Work takes place in a semi paperless environment within an office setting or home office setting, using standard office equipment such as computers, phones, and photocopiers, which requires being stationary for extended periods of time. While performing the duties of this job, the employee is regularly required to talk or hear, and maintain concentration and focus. The employee frequently is required to stand; walk; use hands and fingers, handle or feel; and reach with hands and arms and work with close vision. This position requires the ability to occasionally lift office products and supplies, up to 20 pounds. Work is performed indoors with little to no exposure to extreme outdoor weather conditions. Travel as needed.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
SFM is unique in that we are small enough that your voice is heard, but has all the benefits and perks of a larger employer. We value your opinion, help you reach your goals, and make it easy for you to maintain work-life balance. Find out why our employees rate us a top employer and choose to stay and grow with us. Apply and discover why SFM employees choose to stay with SFM and make it their long-term career. Visit our careers page to learn more about working at SFM.
Since 1983, our mission has been to be the workers' compensation partner of choice for agents, employers and their workers. In that time, we've expanded to well over 25,000 customers in the Midwest and grown our offerings to include vocational rehabilitation, loss prevention, medical services and more. Though much has changed through the years, our focus continues to be unrivaled customer service, safety, and providing better outcomes for employers and injured workers.
SFM Mutual Insurance Company and each of its parent companies, subsidiaries and/or affiliated companies are Equal Opportunity/Affirmative Action Employers. All employment decisions are made without regard to race, color, religion, sex, national origin, age, sexual orientation, marital, familial, or veteran status, medical condition or disability, or any other legally protected classification.
SFM Companies, EEO/AA Employers. SFM is a participant of E-Verify. Applicants have rights under Federal Employment Laws.