Claim Representative

• Handles all aspects of workers' compensation medical only claims from set-up to case closure, ensuring strong customer relations are maintained throughout the process.
• Reviews claim and policy information to provide background for the investigation.
• Conducts three-part (insureds, claimants, and medical providers) investigations, obtaining facts and taking statements as necessary.
• Evaluates the facts gathered through the investigation to determine the compensability and relatedness of the medical treatment.
• Adhere to state regulations for assigned states.
• Adhere to Best Practice guidelines.
• Prepares reports on investigations, settlements, denials of claims, evaluations of involved parties, etc.
• Timely administration of statutory medical only benefits throughout the life of the claim.
• Sets reserves within authority limits for medical and expenses and recommends reserve changes to Supervisor throughout the life of the claim.
• Reviews the claim status at regular intervals and makes recommendations to Supervisor to discuss problems and remedial actions to resolve them.
• Controls and directs vendors and telephonic case managers on medical management.
• Complies with customer service requests, including Special Claims Handling procedures and file status notes.
• Submits workers' compensation forms and electronic data to states to ensure compliance with statutory regulations.
• Refers appropriate claims to subrogation and secures necessary information to ensure that recovery opportunities are maximized.

• Entry-level Medical Only Claim Examiner position.
• Knowledge of insurance, claims, and workers' compensation statutes, regulations, and compliance is a plus, but on-the-job training will be provided to the chosen applicant.
• Ability to incorporate data analytics and modeling into daily activities to expedite the fair and equitable resolution of claims and claim issues.
• A personal commitment to superior performance that adds value to our company and our customers.
• Ability to work effectively with a wide variety of people and in a team environment.
• An aptitude for evaluating, analyzing, and interpreting information.
• Superior customer service showcasing verbal, written, and interpersonal skills.
• Excellent organizational and time management skills which demonstrate the ability to multi-task and prioritize by accomplishing a high volume of tasks and assignments within defined deadlines.
• Adaptability to constantly evolving environments and demonstrable flexibility which meets or exceeds state requirements or customer's expectations.

• Experience, Education, & Requirements

• College degree in any area of study is preferred but not required.
• Prior workers' compensation medical only or similar claim handling experience is a plus but not required.
• Knowledge of medical terminology is a plus but not required.
• Knowledge of bill processing is a plus but not required.
• Proficient computer skills and extensive knowledge of the Microsoft suite of Office products including Outlook, Word, Excel, and PowerPoint.
• Experience in a fast-paced, fluid environment
• If you do not already have one, you will be required to obtain an applicable resident or designated home state adjusters license and possibly additional state licensure.

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