Claims Representative II

Pinnacol Assurance•Denver, CO

2d•$66,500 - $71,800•Onsite

About The Position

Pinnacol Assurance is dedicated to providing workers' compensation protection to Colorado employers and employees, with a focus on innovation and community impact. The Claims Representative II will strategically and proactively manage indemnity claims and related issues to ensure expedient and cost-effective resolutions while providing excellent customer service. This role involves identifying complex claims, collaborating with team members, and ensuring consistent follow-through for efficient claim resolution.

Requirements

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. 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.
Serve as resource to other claims representatives and the discipline as requested.
Perform other duties as assigned.