ESIS Claims Compliance Specialist, WC

JOB DESCRIPTION

The Compliance Specialist is responsible for ensuring regulatory compliance with Nevada Workers' Compensation requirements, with knowledge of California regulations considered an asset.

Reporting to the Claims Vice President, this role manages compliance notices, legal communications, and regulatory inquiries (primarily from the Department of Insurance).

The Compliance Specialist ensures timely and accurate responses, tracks and analyzes trends for root cause analysis, and supports training initiatives for the claims team.

Key Responsibilities:

Compliance & Notice Management


* Receive, acknowledge, and respond to all compliance notices, penalties, and DIR communications in a timely manner.


* Apply jurisdictional knowledge to provide accurate responses, collaborating with legal counsel as needed.


* Track and document all notices, responses, and outcomes for trend analysis and training purposes.

DIR Inquiry & Response Coordination


* Lead the response process for DIR inquiries, including gathering information, coordinating with adjusters and team leaders, and drafting formal responses.


* Set and communicate response deadlines, review research conducted by adjusters, and finalize submissions.


* Assess cases for negotiation opportunities and consult with management as appropriate.

Penalty & Fine Administration


* Manage all fines and penalties, including conducting root cause analysis, preparing documentation, and overseeing approval workflows.


* Provide feedback and training to adjusters and team leaders based on penalty findings.


* Track penalties and trends, and implement process improvements to prevent recurrence.

Incoming Hearing Notices & Legal Mail


* Oversee the intake, indexing, and distribution of new notices and legal mail to the appropriate adjusters and team leaders.


* Ensure prompt escalation of legal and DIR mail by adjusters, with all actions documented in the claim file.


* Track and assign hearings, maintain hearing calendars, and coordinate document preparation.


* Support adjusters and legal counsel in hearing preparation and follow-up activities.

Appeals & Legal Updates


* Track all appeals and obtain necessary approvals for escalations.


* Monitor and communicate legislative and regulatory changes, updating processes and training as required.

Training, Support & Reporting


* Serve as a resource for Nevada procedural questions and compliance best practices.


* Lead bi-weekly reviews to share knowledge, address issues, and identify training needs.


* Maintain comprehensive reports on hearings, denials, appeals, penalties, and legal costs for management review.

Audits/Carrier Support


* Review and prepare files for state and carrier audits, ensuring compliance with carrier guidelines.


* Provide support with carrier reporting and completion of required carrier forms for reportable claims.


* Participate in special...