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TPA Claims Specialist III


MA - Woburn

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General Description: Senior Level lost time claim adjuster for workers compensation


  • Advanced Knowledge of claims function and processes.
  • Ability to effectively communicate with internal and external customers.
  • Expert understanding of workers compensation or disability claims management, strategies, resolution techniques and adjusting.
  • Technical/administrative capability to adjust lost time, utilizing the features of the TPA claim management systems.
  • Participates in claim advocacy and negotiations, including claim denials, reserving files, and claim reporting, issuing payments, attending hearings, conciliations or mediations and filing of state forms.
  • Determine compensability of the claim as it relates to the worker compensation jurisdiction.
  • Review and approval of loss time, medical services and expenses to be paid of the claims file.
  • Plan and attend claim reviews with clients, carriers and auditors.
  • Negotiate and recommend claim file settlements to the client.
  • Ability to identify client issues, build a plan towards resolution, execute and manage internal and external expectations effectively.
  • Analyzes claims based on the TPA best practices as outlined in the "Policy and Procedures" manual.
  • Skill set to implement new business with "Special Account Instructions".
  • Understand the financial impact of losses.
  • Ability to communicate with internal resources to explain results and help develop improvement for risk management plans.
  • Ability to develop high quality output documents for internal resources, clients and carriers
  • Understand client business issues.
  • Attend sales presentations.
  • Act as a team leader with the non lost time claim adjuster and the medical case manager.

Knowledge, Skills and Abilities:

  • Ideal candidate will have a minimum of 10 - 15 years of claims administration experience.
  • College degree preferred but high school diploma or graduate equivalent degree required.
  • Expert in MS Office suite of products, especially MS Excel.
  • Superior written and oral communication skills.
  • Ability to lead a team and work well in a team environment.
  • Must have expert analytical thinking and problem-solving skills.
  • Superior organizational skills required.
  • Expert negotiation skills required.

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