Claim Representative III - Workers Compensation

Church Mutual Insurance Company, S.I.

2d•Remote

About The Position

In accordance with application of state and federal laws and company best practices and under limited supervision, responsible for the investigation, evaluation, and disposition of complex Workers Compensation cases of high exposure and severity. Gather and review claim information, determine coverage, and conduct investigation. Initiate and maintain customer contact to provide updates and resolve any issues with the claim. Update information in the claim system to document claim handling activities. Determine/set reserves and make payments within level of authority. Investigate and refer identified claims to Loss Recovery Services as applicable

Requirements

Five to seven years of claim handling and/or other insurance-related experience is required.
Ability to obtain and maintain state adjusting license requirements and complete continuing education requirements.
Evidence of ability to think independently.
Strong listening, verbal, and written communication skills.
Ability to handle claims in more than one jurisdiction.
Proficient knowledge of policy terminology and legal principles involving at least one or more of the following: insurance, automobile, medical and property claims.

Nice To Haves

Additional training in insurance, medical, and/or building terminology knowledge is desirable.
Completion of INS, AIC, or CPCU is preferred.

Responsibilities

Perform claim tasks timely and document claim files appropriately.
Proactively manage claim activities to ensure fair claim resolution. Handle all claims in accordance with state and federal laws.
Make complex coverage and compensability decisions by gathering information necessary to make an informed decision in a fair, equitable, and ethical manner. Deny losses within authority level/seeking authority as needed, providing detailed explanation, citing facts, and applicable statutory language.
Perform a thorough investigation based upon the type, complexity, and severity of the claim. Upon completion of the investigation, analyze and evaluate the probable exposure. Formulate and document an action plan based on the claim facts and resolution strategy.
Determine and set reserves based on the most probable outcome of the claim, within authority level. Evaluate and negotiate directly with insured, claimant, or claimant's attorney on all cases within authority level. Review claim facts and exposure with claims management, as appropriate, to guide claim strategy. Make complete, accurate, and timely payments within authority for covered losses. Recognize and refer claims above authority to appropriate team member for review and potential reassignment.
Maintain a professional, courteous, and helpful approach when communicating in-person, on the phone, or through email and other correspondence with internal and external customers, business partners and brokers.
Recognize when vendor partners are required on a claim, including experts, nurses, defense attorneys, etc. Assign and direct vendors, as needed, to aid in the investigation evaluation and management of the claim. Manage claim expense by concluding vendor assignment when vendor is no longer adding value to the claim.
Investigate and refer identified claims to Loss Recovery Services, as applicable.
Act as a resource to share knowledge and experience with other claim handlers. Assist and support their development with mentoring and auditing functions.
Attend mediations as requested.