ESIS Claims Compliance Specialist, WC

JOB DESCRIPTION

The Compliance Specialist role requires specific knowledge of Florida jurisdiction workers compensation with additional knowledge of Georgia a plus.

They will report into the Claim Vice President and will be responsible for managing all the EDI, penalties, compliance, legal communications, and regulatory inquiries tracking and identifying trends for root cause analysis and training.

They will further support and help provide education/training to claims adjusters and team leaders to enhance our success in all areas of regulatory compliance.

MAJOR DUTIES & RESPONSIBILITIES:

The Compliance Specialist ensures regulatory compliance and operational excellence in claims handling, supporting adjusters and leaders through expert guidance, training, and process improvement.

This role is critical in minimizing penalties, optimizing audit outcomes, and maintaining high standards of service and compliance.

Compliance & Notice Management


* Receive, acknowledge, and respond to all compliance notices, penalties, and DIR communications timely


* Utilize jurisdictional knowledge to provide appropriate responses, working with counsel as needed


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


* Manage all fines/penalties, including root cause analysis, write-ups, and approval workflows.


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


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


* Track all appeals and secure necessary approvals for escalations.


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


* Serve as a resource for Florida and Georgia 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.


* Review and prepare files for State and carrier audits.

Review files to ensure that they are in compliance with carrier guidelines.


* May provide support with carrier reporting and certain carrier forms (reportable claims)


* Special projects as deemed necessary such as reserve analysis, client specific projects and audits, etc.

QUALIFICATIONS



* 5+ years of experience in claims administration, compliance, or regulatory affairs (insurance industry preferred)


* Experience with claims, compliance, or regulatory environments (Florida required) Active adjuster license or ability to obtain licensure within a specified timeframe is required


* Strong knowledge of regulatory requirements and compliance processes


* Excellent written and verbal communication skills


* Proven ability to manage multiple priorities and deadlines in a fast-paced environment


* High attention to detail and accuracy in docum...