Claims Representative II (Remote)

MEM•St. Louis, MO

6d•Remote

About The Position

MEM Insurance is seeking a Claims Representative to join their collaborative and mission-driven Claims team. In this role, the Claims Representative will manage a caseload of moderately complex workers’ compensation claims, ensuring quality care for injured workers while protecting the financial integrity of their policyholders. The Claims Representative will work closely with internal teams, policyholders, and external partners to investigate claims, develop return-to-work strategies, and negotiate fair settlements. This position is ideal for someone who thrives in a fast-paced environment and is committed to making a meaningful impact.

Requirements

2–4 years of claims handling experience, with a strong preference for workers’ compensation experience.
Associate in Claims (AIC) designation preferred.
Texas All-Lines Adjuster License preferred.

Responsibilities

Investigate and manage moderately complex workers’ compensation claims, ensuring compliance with state laws and MEM guidelines.
Analyze statements and records to determine compensability and communicate findings to stakeholders.
Collaborate with Nurse Case Managers and external vendors to oversee medical case management, including lifetime care planning and permanent restrictions.
Develop tailored Return-to-Work (RTW) strategies in partnership with policyholders, ensuring accommodations align with medical restrictions.
Calculate and issue accurate disability benefits in accordance with statutory requirements.
Identify and investigate potential fraud or abuse in coordination with the Special Investigation Unit.
Establish and maintain appropriate claim reserves, adjusting as needed based on evolving claim circumstances.
Negotiate settlements within authority levels and collaborate with legal counsel on litigated claims.
Ensure Medicare compliance, including coordination of Medicare Set-Aside Trusts when applicable.
Maintain thorough documentation and data accuracy in all claim files and systems.
Provide timely updates on high-exposure or high-profile claims to management.
Collaborate cross-functionally with Underwriting, Premium Consultation, and Loss Prevention teams.
Deliver exceptional service to internal and external customers, including policyholders and producers.
Participate in workflow improvement initiatives and support onboarding of new team members.
Stay current with workers’ compensation laws and best practices through ongoing training and development.