Claim Representative II

Emergent Holdings•MI, MI

3d•$56,700 - $94,900•Onsite

About The Position

This is the intermediate level of the claim handler career path. Handles moderate difficult claims. Exercises progressively more discretion in the determination of compensability of claims. Considers many factors in the determination claim reserves. Negotiates and settles claims within given authority. Administers complex claims and catastrophic exposures within authority, including claims from dedicated large accounts. Exercises independent judgment to settle cases prior to mediation or litigation. Actively participates in agent/client relationship management. Assists in mentoring team members.

Requirements

Three years’ experience in a workers’ compensation claims environment which provides the necessary skills, knowledge, and abilities, such as experience in reviewing, investigating, and closing workers’ compensation claims.
Experience of handling claims in multiple jurisdictions preferred.
One year of AF Group Claims Representative I experience that includes handling of difficult or complex claims.
Ability to make independent decisions.
Ability to solve complex problems.

Nice To Haves

Bilingual skills preferred.
Experience of handling claims in multiple jurisdictions preferred.
Bilingual skills preferred.
Experience of handling claims in multiple jurisdictions preferred.
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.
Facilitate 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 to accurately interpret and apply relevant laws.
Administers complex claims and catastrophic exposures within authority, including claims from dedicated large accounts.
Exercises independent judgment to settle cases prior to mediation or litigation.
Actively participates in agent/client relationship management.
Assists in mentoring team members.