Workers' Comp Claim Representative III - CA

Emergent Holdings•Lansing, MI

About The Position

This is the advanced level of the claim handler career path. The role involves investigating claims and exercising significant discretion in determining compensability. The representative may handle large, more complex customers requiring high-touch, labor-intensive claim service. Responsibilities include considering many factors in determining claim reserves, negotiating and settling claims within given authority, mentoring lower-level claim handlers, coordinating special projects, and providing guidance to others. The candidate must have California experience.

Requirements

Relevant combination of education and experience may be considered in lieu of degree.
Bachelor’s degree in a related field.
Five (5) years of experience in a workers’ compensation claims environment which provides the necessary skills, knowledge and abilities, such as experience in reviewing, investigating and closing complex workers’ compensation claims.
OR Two (2) years of AF Group Claims Representative II experience that includes discretion in determining compensability of complex claims and/or handling complex, high touch or labor-intensive customers.
Candidate must have California experience.
Ability and proficiency in the use of computers and company standard software specific to position.
Knowledge of medical and legal terminology related to work.
Knowledge of workers’ compensation laws and regulations, including jurisdictional laws.
Effective oral and written communication skills.
Effective customer service skills.
Ability to negotiate, build consensus and resolve conflict.
Ability to manage multiple priorities and meet established deadlines.
Attention to detail and analytical skills.
Ability to work independently as well as within a team.
Ability to make independent decisions.
Ability to solve complex problems.
Ability to train and mentor others.

Nice To Haves

Certification or progress toward certification is highly preferred and encouraged.
Experience handling claims in multiple jurisdictions preferred.
Bilingual skills preferred.

Responsibilities

Verifies workers’ compensation coverage of employers and injured employees.
Determines compensability under workers’ compensation by thorough investigation of the claim.
Determines causal relationship between the reported injury and the incident to ensure appropriate payment of benefits.
Facilitates return to work for the injured employee.
Establishes timely and appropriate reserves based on the profile of the claim within given authority based on anticipated financial exposure.
Documents specifics of claims with potential for subrogation recovery, including amount of potential recovery monies.
Manages medical bills for non-indemnity and indemnity claims directly associated with the claimed injury. Approves payment based on knowledge of the treatment plan and medical support showing relationship of treatment to the injury.
Concludes and closes files following resolution of claims to meet internal performance standards while complying with state legislation to avoid penalties and manage expenses.
Negotiates settlements with attorneys or injured parties within given authority at the earliest possible point to bring cases to final disposition.
Works closely with manager on complex files or files above settlement/reserve authority.
Manages outside vendors to ensure cost containment efforts.
Establishes and maintains effective working relationships with all internal and external customers.
Stays abreast of changes in workers’ compensation statutes, case law and rehabilitation efforts/advancements in order to accurately interpret and apply relevant laws.
Mentors team members.
Conducts audits of claim files.
Acts as a backup for team leader.
Coordinates special projects.