Senior Claims Representative

Senior Claims Representative

Primary Purpose

Resolves complex Workers Compensation claims, based on the Supervisors discretion, by investigating, negotiating, and settling claims; conducting onsite and phone interviews of various Workers Compensation claims, within performance/customer service or other standards established by management from time to time.
Essential Functions and Responsibilities

(Other duties may be assigned)

• Conducts phone and field investigations by meeting with claimants, insureds, and witnesses; securing statements; photographing and/or videotaping accident sites; documenting the claims file with the results.
• Completes lost time Workers Compensation claims by evaluating, applying knowledge and expertise to determine the liability of the claim.
• Determines the insurance carriers liability by reviewing the facts of the cases, setting case reserves, calculating and paying the appropriate benefits.
• Determines the desirability of obtaining records review and independent medical examinations (IME) by reviewing the facts of the case and posing questions to independent medical personnel and taking the appropriate    action with the results.
• Promotes early return to work by communicating and coordinating between involved personnel.
• Resolves litigated claims by referring cases to attorneys, analyzing state statutes, evaluating evidence and working with the attorneys in developing strategy for resolution of the case.
• Pursues subrogation recoveries from potentially responsible third parties by reviewing the facts and determining liability.
• Communicates decisions on cases by responding to communications from: supervisors, claimants, claimants counsel, insured employers, agents, health care providers, state administrators and others.
• Ensures accurate file documentation by complying with company procedures and state requirements.
• Determines the need for medical and vocational management by reviewing the severity of the claim, assigning vendors and directing their activities.
• Keeps focus with continued file handling by collecting, analyzing and summarizing information, as well as making recommendations to supervisors regarding reserve changes and future handling of files over his/her authority level.
• Serves customers by providing product and service information; resolving product and service problems.
• Supports after-hours claims emergencies by being on call 24 hours per day, seven days per week.

Required:

• 4-6 years of directly related experience involving the exercise of discretionary decision-making.
• Bachelors degree in business or related field or equivalent experience. *Equivalent experience may be deemed to be approximately 4-6 years of directly related experience involving the exercise of discretionary decision-making as determined by Society Insurance.
• Valid drivers license and a satisfactory driving record as determined by Society Insurance.

Preferred:

• 2+ years of field workers compensation adjusting experience.
• Proficient investigative skills, demonstrated through experience.
• Continued education in related field and/or experience with medical terminology and workers compensation laws and procedures.
• Demonstrated knowledge of general office equipment (computer, Dictaphone, telephone, calculator, fax machine, headsets and copy machines).

Hours and Travel:

• At times unusual working hours and necessary travel throughout surrounding states and those that Society performs business in are required; at times overnight travel occurs, as well.