Claims Representative

Pinnacol Assurance•Denver, CO

1d•$60,000 - $64,200•Onsite

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.

Requirements

2 or more years previous experience working directly with customers
comfortable managing difficult conversations
Must be comfortable using technology and multiple systems
Must successfully complete training and claims assessments within six months.

Responsibilities

Work with team members to strategically and proactively manage claims and claim-related issues to the most expedient, cost effective resolution; provide quality customer service to all stakeholders.
Identify claims that need additional management and work with team members to resolve concerns or escalate to the appropriate level.
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.
Effectively 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, etc..
Facilitate 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, Claims Director, Claims Specialist and Claims Manager.
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.
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 required by Company best practices, case law and the Colorado Workers’ Compensation Act.
Evaluate and negotiate claims for settlement as required by Company best practices.
Educate and inform policyholders and agents on workers compensation and the status of individual claims status and significant development as required by Company best practices.
Review all medical information received on claims periodically in order to determine if authorization/payment is appropriate, or a 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 on all open claims according to company best practices.
Prepare for, attend and testify at settlement conferences and hearings as determined appropriate by leadership.
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 as requested by the business team as well as the claims discipline as needed.
Serve on projects and committees as requested.
Continue education toward management of increasingly more complicated claims to prepare for Claims Representative II.
Other duties as requested.