Workers' Compensation Claims Representative

Workers' Compensation Claims Representative

** This is an entry-level position.

Primary Purpose

Resolves Workers Compensation claims of a more difficult and complex nature, based on the Supervisors discretion, by investigating, evaluating, documenting and negotiating settlements within performance/customer service or other standards established by management from time to time.

Essential Functions and Responsibilities

(Other duties may be assigned)

• Investigates more complex workers compensation claims, of significant injury and/or of a highly questionable nature, by conducting recorded telephone statements of injured workers, insureds and witnesses and documenting claim files with results.
• 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, injured workers, injured workers 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.

Required:

• A Bachelors degree in business or related field and/or 5 or more years of loss of time claims handling experience.
• Valid drivers license and a satisfactory driving record as determined by Society Insurance.

Preferred:

• A Bachelors degree with related claims handling experience.
• Proficient investigative skills, demonstrated through experience.
• Continued education in and/or experience with medical terminology and workers compensation laws and procedures.
• Demonstrated knowledge of general office equipment (computer, typewriter, dictaphone, telephone, calculator/adding machine, fax machine, headsets and copy machines).