Senior Workers Compensation Claim Representative

Travelers•Diamond Bar, 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 office out of the Diamond Bar or Irvine location. Under general supervision, this role manages Workers' Compensation claims with lost time to conclusion and negotiates settlements where appropriate. The representative coordinates the medical and indemnity position of the claim with a Medical Case Manager. The role independently handles assigned claims of low to moderate complexity, where wage loss is expected to result in a return to work (modified or full duty) or Maximum Medical Improvement (MMI) with no return to work. These claims may involve minor sprains or minor to moderate surgery, with the injured worker receiving ongoing medical treatment or permanent partial disability (PPD) benefits after returning to work and reaching MMI. The claim will close once PPD is paid out. The role also independently handles all assigned claims up to and including the most complex, where the injured worker remains out of work and is unlikely to return to their position, the employer cannot accommodate restrictions, or the claim involves moderate to complex litigation issues. This includes claims where the injured worker has returned to work, reached MMI, and has PPD, with the file litigated to dispute the permanency rating and/or causality. It also covers claims where the injured worker is released to work with permanent restrictions and the job is no longer available, or the injured worker is receiving Vocational Rehabilitation. Claims that have been reopened for additional medical treatment on more complex files are also managed. Injuries may involve one or multiple back, shoulder, or knee surgeries, knee replacements, claims involving moderate to complex offsets, permanent restrictions, and/or fatalities. Claims on which a settlement should be considered are also part of the responsibilities.

Requirements

High school diploma or equivalent.
2 years Workers Compensation claim handling experience.

Nice To Haves

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.

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, proper documentation, and proactive resolution of outstanding issues.
Achieve a positive end result by returning the injured party to work and coordinating appropriate medical treatment in collaboration with internal nurse resources.
Develop strategies to manage losses involving issues of statutory benefit entitlement, medical diagnoses, and Medicare Set Aside to achieve resolution.
Work in collaboration with specialty resources (medical and legal) to proactively pursue claim resolution opportunities.
Collaborate with internal nurse resources (Medical Case Manager) 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.
Perform other assigned duties which may include applying deep technical/subject matter expertise to assist in the resolution of complex claims.
Act as an independent mentor to other Claim Professionals.
May be dedicated to and apply skills necessary to manage special account relationships.
May primarily manage a specialized inventory of Workers’ Compensation claims.
Acquisition and maintenance of Insurance License(s) may be required.
Maintain Continuing Education requirements as required.
Perform other duties as assigned.