Claim Representative I - WI

Blue Cross Blue Shield of Michigan•Lansing, WI

2d•Onsite

About The Position

This is an entry-level professional claim handler position responsible for managing medical-only and indemnity benefits. The role involves exercising discretion in determining claim compensability, considering various factors for claim reserves, and negotiating and settling claims within given authority. The position requires verifying workers' compensation coverage, conducting thorough investigations to determine compensability and the causal relationship between injury and incident, and facilitating return to work for injured employees. It also involves establishing timely and appropriate reserves, documenting claims with potential for subrogation recovery, managing medical bills, approving payments based on treatment plans and medical support, and concluding/closing files to meet performance standards and comply with state legislation. The role includes negotiating settlements, working with managers on complex files, managing outside vendors for cost containment, and maintaining effective customer relationships. Staying updated on workers' compensation statutes, case law, and rehabilitation advancements is crucial for accurate interpretation and application of laws. This description outlines typical responsibilities, but other essential functions may be required.

Requirements

Bachelor’s degree in a related field. Relevant combination of education and experience may be considered in lieu of degree.
Continuous learning, as defined by the Company’s learning philosophy, is required.
Minimum one-year relevant experience that provides the necessary skills, knowledge and abilities or completion of claims trainee program.
Ability and proficiency in the use of computers and company standard software specific to position.
Knowledge of medical and legal terminology related to the work.
Knowledge of workers’ compensation laws and regulations, including jurisdictional laws.
Effective oral and written communication skills.
Effective customer service skills.
Ability to negotiate, build consensus and resolve conflict.
Ability to manage multiple priorities and meet established deadlines.
Attention to detail and analytical skills.
Ability to work independently as well as within a team.

Nice To Haves

Certification or progress toward certification is highly preferred and encouraged.
Bilingual skills preferred.

Responsibilities

Verifies workers’ compensation coverage of employers and injured employees.
Determines compensability under workers’ compensation by thorough investigation of the claim.
Determines causal relationship between the reported injury and the incident to ensure appropriate payment of benefits.
Facilitates return to work for the injured employee.
Establishes timely and appropriate reserves based on the profile of the claim within given authority based on anticipated financial exposure.
Documents specifics of claims with potential for subrogation recovery, including amount of potential recovery monies.
Manages medical bills for non-indemnity and indemnity claims directly associated with the claimed injury.
Approves payment based on knowledge of the treatment plan and medical support showing relationship of treatment to the injury.
Concludes and closes files following resolution of claims to meet internal performance standards while complying with state legislation to avoid penalties and manage expenses.
Negotiates settlements with attorneys or injured parties within given authority at the earliest possible point to bring cases to final disposition.
Works closely with manager on complex files or files above settlement/reserve authority.
Manages outside vendors to ensure cost containment efforts.
Establishes and maintains effective working relationships with all internal and external customers.
Stays abreast of changes in workers’ compensation statutes, case law and rehabilitation efforts/advancements in order to accurately interpret and apply relevant laws.