Associate Claims Representative (Remote)

About the role

MEM Insurance is seeking an Associate Claims Representative to join our dedicated Claims team. This role involves independently managing a caseload of workers’ compensation claims, investigating coverage and compensability, coordinating medical care, managing disability and return-to-work processes, and supporting fair, well-documented claim resolutions.

Responsibilities

• Conduct thorough investigations of workers’ compensation claims, including coverage analysis, compensability decisions, and collection of statements and documentation.
• Identify coverage concerns, subcontractor issues, or other complexities and escalate when appropriate.
• Maintain well-organized claim files with clear documentation, action plans, and timely updates.
• Establish, monitor, and adjust reserves to ensure accuracy and alignment with corporate expectations.
• Manage claims from initial report through final disposition, prioritizing workload to meet quality and productivity standards.
• Oversee the medical aspects of claims, ensuring injured workers receive appropriate, cost-effective treatment.
• Collaborate with network providers, Nurse Case Management, Utilization Management, and specialists to guide care decisions.
• Review and process medical bills with accuracy and timeliness.
• Secure wage statements, calculate disability benefits correctly, and ensure payments follow statutory requirements.
• Manage Return-to-Work efforts, educating policyholders on light-duty options and helping employees resume safe, meaningful work.
• Identify potential fraud indicators and collaborate with the Special Investigations Unit as needed.
• Investigate subrogation opportunities and document third-party liability to maximize recovery.
• Navigate Medicare exposure appropriately, securing Medicare Set-Asides when required.
• Identify opportunities for structured settlements.
• Communicate claim status to policyholders, producers, and internal stakeholders with professionalism and clarity.
• Provide claim updates on high-profile or high-dollar cases as requested.
• Partner with Underwriting, Premium Consultation, and Loss Prevention on risk concerns and claim trends.
• Support team members when colleagues are out of office.
• Engage in ongoing learning to stay current with workers’ compensation laws, regulations, and industry practices.
• Assist in onboarding and supporting new Claims team members.

Qualifications

• Education: High school diploma or equivalent experience required; bachelor’s degree preferred.
• Experience: 1–2 years of claims handling experience with exposure to workers’ compensation preferred.
• Licenses: Valid driver’s license required.
• Certifications: AIC or other insurance designations preferred.