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Vensure Employer Solutions, the largest privately held HR technology and service organization, is seeking a Senior Workers' Compensation Claims Specialist to manage complex multi-state workers' compensation claims with minimal supervision. You will serve as a strategic consultant to clients, overseeing claims from inception through closure while ensuring effective and efficient adjudication.
Key Responsibilities:
- Lead comprehensive investigations of complex workers' compensation claims, including coverage analysis, compensability determinations, medical review, and detailed findings with strategic recommendations to third-party administrators (TPAs).
- Evaluate and respond to TPA requests for reserve and settlement authority, conducting advanced exposure assessments based on medical prognosis, statutory benefits, vocational factors, and litigation risk.
- Perform sophisticated claim evaluations to identify high-risk factors, subrogation opportunities, and long-term cost drivers, advising clients on proactive mitigation strategies.
- Serve as a high-level consultant on risk mitigation, analyzing claim trends, identifying systemic issues, and recommending safety improvements to reduce workplace injuries.
- Provide empathetic, expert-level communication to injured workers, offering clear guidance and acting as a knowledgeable advocate while balancing employer interests.
- Support clients in developing and optimizing return-to-work programs, including identifying alternative/light-duty assignments and evaluating functional capacity.
- Act as a strategic liaison between clients, TPA adjusters, defense counsel, medical providers, and injured employees, ensuring coordinated case management and reduced litigation exposure.
- Continuously monitor claim progression, ensuring timely action on medical updates, legal developments, and compliance with jurisdictional requirements.
- Manage a portfolio of complex claims, directing claim strategies and driving timely resolution through expert guidance.
- Identify process improvements leveraging data and claim trends to enhance program effectiveness.
- Mentor and support junior claims staff, sharing expertise and contributing to best-practice procedures.
- Maintain regular in-office attendance at the Phoenix, AZ location; occasional domestic travel required for team meetings, client visits, and industry conferences.
Requirements:
- Bachelor's degree preferred in Risk Management, Business Administration, Human Resources, or equivalent combination of experience, skills, education, certifications, or job training programs.
- 4–5 years of progressively responsible multi-state workers' compensation claims experience, ideally in a TPA, insurance carrier, or employer-based risk management environment.
- Demonstrated expertise managing complex, high-exposure, and litigated claims, including catastrophic injuries and long-term medical management.
- Proven experience conducting in-depth investigations, evaluating compensability, analyzing medical documentation, and determining financial exposure.
- Experience collaborating with TPA adjusters, defense attorneys, medical providers, vocational professionals, and employer leadership.
- Strong background in return-to-work coordination and developing light-duty programs.
- Experience providing client consultation, program improvement recommendations, and training on workers' compensation practices and regulatory compliance.
- In-depth knowledge of workers' compensation laws, statutes, and regulations across multiple jurisdictions.
- Expert understanding of claims investigation techniques, compensability analysis, and advanced risk assessment.
- Extensive knowledge of medical terminology, treatment guidelines, return-to-work principles, and rehabilitation processes.
- Strong understanding of litigation processes, legal strategy, attorney management, settlement negotiation, and mediation practices.
- Advanced knowledge of reserve setting and financial exposure analysis.
- Exceptional analytical and critical-thinking skills.
- High-level communication and interpersonal skills.
- Strong negotiation skills.
- Advanced case-management and organizational skills with ability to manage high-volume or high-complexity caseloads.
- Proficiency in claims software, medical management systems, and advanced Excel skills.
- Expert documentation and reporting skills.
- Strong client-relationship and consultative skills.
- Ability to work effectively under supervision while demonstrating initiative and accountability.
- Proficiency with Microsoft Office software (Outlook, Teams, Excel, Word, PowerPoint).
- Advanced professional designations such as WCCA/WCCP, AIC, ARM, CWCP, or CPCU are desired.
