Claims Representative II

Pinnacol Assurance • Denver, CO

12h

About The Position

Pinnacol Assurance does just one thing, and does it better than anyone: provide caring workers’ compensation protection to Colorado employers and employees. And while we may be a little biased, we believe that our work shapes communities and changes lives.
We have big hearts and love big ideas. We’ve been around for more than 100 years, but don’t let that fool you. Pinnacol is committed to taking care of Colorado employers and workers in the most innovative ways. We celebrate continuous improvement, new ideas, compassion, teamwork, integrity and excellence.
What you’ll do:
Work with team members to strategically and proactively manage indemnity claims and claim-related issues to the most expedient, cost effective resolution; provide quality customer service to all stakeholders which includes proactive communication and follow through at all times. Identify claims that need complex management and work with team members to resolve concerns or escalate to the appropriate level or secure appropriate resources. Must demonstrate consistent follow through with all stakeholders to ensure efficient and effective resolution of each issue and claim.
What you can expect:
Contact stakeholders as required by Company best practices on incoming claims to promptly investigate circumstances of accident and injury, investigate and determine compensability, and identify and address red flag issues, including late reporting, pre-existing medical issues, designated medical provider process and referral issues, medical treatment issues, legal issues, and potential subrogation and penalty issues. Be able to manage the relationships with your stakeholders in order to obtain timely and accurate information in order to complete this process. Effectively and proactively communicate your decisions and evaluate for customer understanding.
Determine compensability as required by Company best practices, case law and the Colorado Workers' Compensation Act.
Proactively manage open claims as required by Company best practices, including expedient and cost effective medical case management, disability management, and litigation management, as well as identification, investigation, management and resolution of potential adverse claim development, including prior injuries, comorbid and pre-existing medical conditions, migrating body parts, worsening medical conditions and delayed recovery, change of physician requests, multiple claims, multiple jobs, subrogation, penalties and offsets.
Coordinate and oversee all necessary resources on a timely basis for optimal claim management, action plan development and claim resolution, including other claims team members, Claims Lead, Claims Owners, Underwriter, Business Director, Legal resources, Return-to-Work Consultant, Safety Consultant, Medical Case Manager, Utilization Review, MedPay Liaison, Provider Relations Specialist and Claims Director.
Proactively communicate and correspond with stakeholders as needed to manage and resolve open claims, including but not limited to policyholders, injured workers, agents, medical providers, service vendors and resources, attorneys and regulatory agency representatives. Correspondence includes phone, email, fax, possible face to face meetings, and accurate claim documentation.
Facilitate early return to work for injured workers by working with policyholder, and Return-to-Work Consultant if needed.
Facilitate and coordinate benefit authorization and payment on compensable claims as well as filing all appropriate paperwork with the Colorado DOWC as required by Company best practices, case law and the Colorado Workers' Compensation Act.
Evaluate claims for settlement by determining most likely medical path and return to work possibilities. May include estimation of indemnity benefits including permanent impairment. Negotiate settlement with the help of in house or external legal counsel. Negotiate settlement directly with injured workers or their counsel. Facilitate completion of settlement documents and obtain approval from the DOWC as required by Company best practices.
Inform policyholders and agents of claim status and significant development as required by Company best practices.
Review medical information received on claims to determine if authorization/payment is appropriate, or if referral is needed to other Company resources (utilization review, medical case manager, physician advisor, or others) as required by Company best practices and in compliance with DOWC Rules of Procedure.
Set and maintain current, accurate and adequate reserves by reviewing medical records and determining the likely future treatment for the specific injury and circumstances. Must utilize knowledge of likely treatment and outcomes for a variety of injuries, as well as predict the cost of that treatment. Must actively monitor and update current reserves by re-evaluating changing circumstances on all open claims.
Prepare for, attend and testify at settlement conferences and hearings.
Evaluate medical bill referrals to determine relatedness to claim and appropriateness of the bill as required by Company documented best practices. Authorize payment of the bill or deny bill by obtaining appropriate supporting documentation. Communicate decisions to billers and parties to the claim.
Read and analyze medical records in order to maintain a current and accurate understanding of a claims' medical progress. Recognize when a treatment plan is outside of the authorized care. Communicate with internal and external resources to assist stakeholders with their management of the treatment plan. Process records as required by Company documented best practices.
ADDITIONAL DUTIES
Serve as resource to other claims representatives and the discipline as requested.
Perform other duties as assigned.

Requirements

• A successful candidate will have 1 or more years previous experience managing Colorado workers' compensation claims.
• Must have a working knowledge of all required computer systems.
• Must be meeting or exceeding all CR1 metrics and have been working towards indemnity claims proficiency.

Responsibilities

• Work with team members to strategically and proactively manage indemnity claims and claim-related issues to the most expedient, cost effective resolution
• Provide quality customer service to all stakeholders which includes proactive communication and follow through at all times.
• Identify claims that need complex management and work with team members to resolve concerns or escalate to the appropriate level or secure appropriate resources.
• Demonstrate consistent follow through with all stakeholders to ensure efficient and effective resolution of each issue and claim.
• Contact stakeholders as required by Company best practices on incoming claims to promptly investigate circumstances of accident and injury, investigate and determine compensability, and identify and address red flag issues, including late reporting, pre-existing medical issues, designated medical provider process and referral issues, medical treatment issues, legal issues, and potential subrogation and penalty issues.
• Manage the relationships with your stakeholders in order to obtain timely and accurate information in order to complete this process.
• Effectively and proactively communicate your decisions and evaluate for customer understanding.
• Determine compensability as required by Company best practices, case law and the Colorado Workers' Compensation Act.
• Proactively manage open claims as required by Company best practices, including expedient and cost effective medical case management, disability management, and litigation management, as well as identification, investigation, management and resolution of potential adverse claim development, including prior injuries, comorbid and pre-existing medical conditions, migrating body parts, worsening medical conditions and delayed recovery, change of physician requests, multiple claims, multiple jobs, subrogation, penalties and offsets.
• Coordinate and oversee all necessary resources on a timely basis for optimal claim management, action plan development and claim resolution, including other claims team members, Claims Lead, Claims Owners, Underwriter, Business Director, Legal resources, Return-to-Work Consultant, Safety Consultant, Medical Case Manager, Utilization Review, MedPay Liaison, Provider Relations Specialist and Claims Director.
• Proactively communicate and correspond with stakeholders as needed to manage and resolve open claims, including but not limited to policyholders, injured workers, agents, medical providers, service vendors and resources, attorneys and regulatory agency representatives. Correspondence includes phone, email, fax, possible face to face meetings, and accurate claim documentation.
• Facilitate early return to work for injured workers by working with policyholder, and Return-to-Work Consultant if needed.
• Facilitate and coordinate benefit authorization and payment on compensable claims as well as filing all appropriate paperwork with the Colorado DOWC as required by Company best practices, case law and the Colorado Workers' Compensation Act.
• Evaluate claims for settlement by determining most likely medical path and return to work possibilities.
• Estimate indemnity benefits including permanent impairment.
• Negotiate settlement with the help of in house or external legal counsel.
• Negotiate settlement directly with injured workers or their counsel.
• Facilitate completion of settlement documents and obtain approval from the DOWC as required by Company best practices.
• Inform policyholders and agents of claim status and significant development as required by Company best practices.
• Review medical information received on claims to determine if authorization/payment is appropriate, or if referral is needed to other Company resources (utilization review, medical case manager, physician advisor, or others) as required by Company best practices and in compliance with DOWC Rules of Procedure.
• Set and maintain current, accurate and adequate reserves by reviewing medical records and determining the likely future treatment for the specific injury and circumstances.
• Actively monitor and update current reserves by re-evaluating changing circumstances on all open claims.
• Prepare for, attend and testify at settlement conferences and hearings.
• Evaluate medical bill referrals to determine relatedness to claim and appropriateness of the bill as required by Company documented best practices.
• Authorize payment of the bill or deny bill by obtaining appropriate supporting documentation.
• Communicate decisions to billers and parties to the claim.
• Read and analyze medical records in order to maintain a current and accurate understanding of a claims' medical progress.
• Recognize when a treatment plan is outside of the authorized care.
• Communicate with internal and external resources to assist stakeholders with their management of the treatment plan.
• Process records as required by Company documented best practices.
• Serve as resource to other claims representatives and the discipline as requested.
• Perform other duties as assigned.

Benefits

• Our benefits go beyond the basics. You’ll get to choose from diverse benefit offerings for medical, dental and vision.
• We care about each other. We enjoy a positive, collaborative work environment. We are hard workers and high performers.
• We love who you are. Pinnacol is on a journey to embody diversity, equity and inclusion. We’re committed to creating a culture that deeply values differences, where everyone feels like they belong.
• Take a day (or 20!) off. Enjoy 20 paid days off your first full year plus 9 paid holidays.
• Take care of yourself. Sign up for unique wellness programs, including on-site, company-paid fitness facilities and classes
• We promote a learning culture to help you master your current job and cultivate the skills of the future through a variety of on-site, online, and off-site professional development opportunities.
• Through our employee volunteer program, Pinnacol in Action, employees receive paid time off to volunteer with Colorado nonprofits.
• You’ll have the opportunity to earn a quarterly incentive, up to 12 percent of your annual base salary, when your team exceeds their goals and objectives.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed