About the position
As a Claims Representative, you will be responsible for the investigation, evaluation, mitigation and resolution of medical only and lost time workers' compensation claims of moderate complexity in multiple jurisdictions. You will investigate workers' compensation claims by interviewing injured workers, witnesses, and policyholders to verify coverage and determine compensability and benefits due. You will also calculate and set timely financial reserves and proactively manage reserve adequacy throughout the claim lifecycle. Additionally, you will record and code injured worker demographics, job information and accident information in the company's claims management system and file necessary forms with state regulatory agencies. Your role will include issuing timely payments to injured workers, medical providers and service vendors, coordinating and actively managing medical treatment of injured workers to ensure timely rehabilitation, and negotiating settlements of claims within designated authority with injured workers and attorneys. You will demonstrate a working knowledge of the Workers' Compensation Act, adjudication process, and regulatory compliance framework in assigned jurisdictions. Regular communication of claim activity and status updates to policyholders, injured workers and other interested parties in a professional, thoughtful and tactful manner is essential. You will also manage the claims litigation process to ensure timely and cost-effective claims resolution and monitor the expenses and effectiveness of managed care and investigation vendors. Additionally, you will actively participate in special projects as assigned by management and periodically travel to attend hearings, conferences and training sessions.
Responsibilities
- Investigate workers' compensation claims by interviewing injured workers, witnesses, and policyholders to verify coverage and determine compensability and benefits due
- Calculate and set timely financial reserves and proactively manage reserve adequacy throughout claim lifecycle
- Record and code injured worker demographics, job information and accident information in the company's claims management system and file necessary forms with state regulatory agencies
- Issue timely payments to injured workers, medical providers and service vendors
- Coordinate and actively manage medical treatment of injured workers to ensure timely rehabilitation
- Negotiate settlements of claims within designated authority with injured workers and attorneys
- Demonstrate a working knowledge of the Workers' Compensation Act, adjudication process, and regulatory compliance framework in assigned jurisdictions
- Identify and manage subrogation, Second Injury Fund and joint coverage recovery opportunities
- Regularly communicate claim activity and status updates to policyholders, injured workers and other interested parties in a professional, thoughtful and tactful manner
- Respond in a timely manner to communications from policyholders, injured workers, and other interested parties
- Notify management and develop reports for large exposure claims and comply with reinsurance reporting requirements
- Manage the claims litigation process to ensure timely and cost-effective claims resolution
- Monitor the expenses and effectiveness of managed care and investigation vendors
- Actively participate in special projects as assigned by management
- Periodically travel to attend hearings, conferences and training sessions
- Attend and participate in claim file reviews with management and defense attorneys
- Continuously strive to improve our product and business results through innovation
- Obtain and maintain adjuster licenses in assigned jurisdictions as required
Requirements
- Excellent written and verbal communication skills
- Strong interpersonal and relationship building skills
- Exceptional time management and organization skills
- Strong analytical and critical thinking skills
- Ability to work independently and strategically problem solve
- Ability to diplomatically manage conflict
- Ability to develop relationships within the organization and work effectively across departments
- Strong discretion and integrity in dealing with highly confidential and sensitive information
- Detail oriented
- Bachelors' degree or equivalent insurance industry work experience
Benefits
- Health insurance
- Dental insurance
- Vision insurance
- Life insurance
- Disability insurance
- Wellness programs
- Paid time off
- 401(k)
- Profit-sharing plans
