Senior Workers' Compensation Claim Representative

Travelers•Irvine, CA

1d•Hybrid

About The Position

This role is eligible for a sign-on bonus and a hybrid schedule, allowing employees to work up to 2 days per week at their primary residence. The position will be based out of the Diamond Bar or Irvine locations. Under general supervision, the Senior Workers' Compensation Claim Representative will manage Workers' Compensation claims with lost time to conclusion, negotiating settlements where appropriate. This involves coordinating the medical and indemnity position of the claim with a Medical Case Manager. The role independently handles assigned claims of low to moderate complexity, focusing on return to work or reaching Maximum Medical Improvement (MMI) with no Return to Work (RTW). Claims may involve minor sprains or minor to moderate surgery, with the injured worker potentially working modified duty and receiving ongoing medical treatment, or having returned to work and receiving PPD benefits. The position also independently handles more complex claims where the injured worker is unlikely to return to their previous position, the employer cannot accommodate restrictions, or there are moderate to complex litigation issues. This includes claims involving multiple surgeries, permanent restrictions, fatalities, and those requiring settlement consideration. The role requires conducting investigations, assessing policy coverage, establishing and updating reserves, determining causal relatedness of medical conditions, and managing files with an emphasis on quality and proactive resolution. The goal is to achieve a positive end result by returning the injured party to work and coordinating appropriate medical treatment. Strategies will be developed to manage losses involving statutory benefit entitlement, medical diagnoses, and Medicare Set Aside. Collaboration with specialty resources, including internal nurse resources (Medical Case Manager) and legal counsel, is essential for claim resolution. The role involves preparing necessary letters and state filings, pursuing offset opportunities, evaluating claims for potential fraud, and proactively managing inventory to ensure timely file closing or reassignment. The representative will proactively manage moderate to complex litigation, understand and apply Medicare Set Asides, and negotiate settlements within designated authority, potentially using structured settlements or annuities. Deep technical expertise is applied to assist in resolving highly complex claims, and the role includes mentoring other Claim Professionals, participating in file reviews, responding to inquiries, and keeping injured workers informed of claim status. The position may also involve managing special account relationships or specialized claim inventories. Acquisition and maintenance of Insurance License(s) may be required, along with ongoing continuing education.

Requirements

High school diploma or equivalent.
2 years Workers Compensation claim handling experience.
Analytical Thinking: Identifies current or future problems or opportunities; analyzes, synthesizes and compares information to understand issues; identifies cause/effect relationships; and explores alternative solutions that support sound decision-making.
Communication: Expresses, summarizes and records thoughts clearly and concisely orally and in writing by applying proper content, format, sentence structure, grammar, language and terminology. Ability to effectively present file resolution to internal and/or external stakeholders.
Negotiation: Advanced evaluation, negotiation and case resolution skills. Ability to understand alternatives, influence stakeholders and reach a fair agreement through discussion and compromise.
General Insurance Contract Knowledge: Interprets policies and contracts, applies loss facts to policy conditions, and determines whether or not a loss comes within the scope of the insurance contract.
Principles of Investigation: Intermediate investigative skills including the ability to take statements. Follows a logical sequence of inquiry with a goal of arriving at an accurate reconstruction of events related to the loss.
Value Determination: Advanced ability to determine liability and assigns a dollar value based on damages claimed and estimates, sets and readjusts reserves.
Settlement Techniques: Advanced ability to assess how a claim will be settled, when and when not to make an offer, and what should be included in the settlement offer package.
Legal Knowledge: Thorough knowledge, understanding and application of state, federal and regulatory laws and statutes, rules of evidence, chain of custody, trial preparation and discovery, court proceedings, and other rules and regulations applicable to the insurance industry.
Medical knowledge: Intermediate knowledge of the nature and extent of injuries, periods of disability, and treatment needed.
WC Technical: Advanced ability to demonstrate understanding of WC Products and ability to apply available resources and technology to resolve claims. Demonstrate a clear understanding and ability to work within jurisdictional parameters within their assigned state.
Advanced knowledge, understanding and application of state, federal and regulatory laws and statutes, rules of evidence, chain of custody, trial preparation and discovery, court proceedings, and other rules and regulations applicable to the insurance industry.
Customer Service: Advanced ability to build and maintain productive relationships with our insureds and deliver results with optimal outcomes.
Teamwork: Advanced ability to work together in situations when actions are interdependent and a team is mutually responsible to produce a result.
Planning & Organizing: Advanced ability to establish a plan/course of action and contingencies for self or others to meet current or future goals.
In order to perform the essential functions of this job, acquisition and maintenance of Insurance License(s) may be required to comply with state and Travelers requirements. Generally, license(s) must be obtained within three months of starting the job and obtain ongoing continuing education credits as mandated.

Responsibilities

Conduct investigations, including assessing policy coverage, contacting insureds, injured workers, medical providers, and other parties to determine compensability.
Establish and update reserves to reflect claim exposure and document rationale.
Identify and set actuarial reserves.
Apply knowledge to determine causal relatedness of medical conditions.
Manage files with an emphasis on file quality (including timely contact and proper documentation and proactive resolution of outstanding issues).
Achieve a positive end result by returning injured party to work and coordinating the appropriate medical treatment in collaboration with internal nurse resources where appropriate.
Develop strategies to manage losses involving issues of statutory benefit entitlement, medical diagnoses, Medicare Set Aside to achieve resolution through the best possible outcome.
Work in collaboration with specialty resources (i.e. medical and legal) to proactively pursue claim resolution opportunities, (i.e. return to work, structured settlement, and discontinuation of benefits through litigation).
Collaborate with our internal nurse resources (Medical Case Manager) in order to integrate the delivery of medical services into the overall claim strategy.
Prepare necessary letters and state filings within statutory limits.
Pursue all offset opportunities, including apportionment, contribution and subrogation.
Evaluate claims for potential fraud.
Proactively manage inventory with documented plans of action to ensure timely and appropriate file closing or reassignment.
Proactively manage moderate to complex litigation to drive files to an optimal outcome, including resolution of benefits.
Understand and apply Medicare Set Asides and allocations.
Negotiate settlement of claims within designated authority.
May use structured settlement/annuity as appropriate for the jurisdiction.
Apply deep technical expertise to assist in the resolution of highly complex claims.
Mentor other Claim Professionals.
Participate in Telephonic and/or onsite File Reviews.
Respond to inquiries – verbal and written.
Keep injured worker apprised of claim status.
Act as technical resource to others.
Engage specialty resources as needed.
Performs other assigned duties which may include: Applies deep technical/subject matter expertise to assist in the resolution of complex claims.
Acts as an independent mentor to other Claim Professionals.
May be dedicated to and apply skills necessary to manage special account relationships (sensitive or complex).
May primarily manage a specialized inventory of Workers’ Compensation claims.
Maintain Continuing Education requirements as required.
Perform other duties as assigned.