Claim Representative I

About Our Client

The organization operates within the workers’ compensation insurance sector, addressing the complexities involved in managing claims related to workplace injuries. It focuses on ensuring accurate determination of claim compensability, appropriate benefit payments, and effective management of medical and indemnity claims across various levels of claim complexity.

About the Opportunity

The Claim Representative I role is an entry-level position responsible for handling medical-only and indemnity benefit claims. The position requires exercising discretion in determining claim compensability, establishing reserves, and negotiating settlements within defined authority. This role contributes to efficient claims processing and supports injured employees’ return to work.

Responsibilities

• Verify workers’ compensation coverage for employers and injured employees.
• Investigate claims to determine compensability under workers’ compensation.
• Assess causal relationship between injury and incident to ensure proper benefit payments.
• Facilitate return-to-work processes for injured employees.
• Establish timely and appropriate claim reserves within authorized limits.
• Document claims with potential for subrogation recovery.
• Manage medical bills related to claims, approving payments based on treatment relevance.
• Close claims files following resolution in compliance with internal standards and state legislation.
• Negotiate settlements with attorneys or injured parties within authority.
• Collaborate with management on complex or high-value claims.
• Manage external vendors to support cost containment.
• Maintain effective relationships with internal and external stakeholders.
• Stay updated on workers’ compensation laws, case law, and rehabilitation advances.

Requirements

• Bachelor’s degree in a related field or equivalent education and experience.
• Minimum of one year relevant experience or completion of a claims trainee program.
• Proficiency with computers and relevant software.
• Knowledge of medical and legal terminology related to workers’ compensation.
• Understanding of workers’ compensation laws and jurisdictional regulations.
• Effective oral and written communication skills.
• Strong customer service capabilities.
• Negotiation, consensus-building, and conflict resolution skills.
• Ability to manage multiple priorities and meet deadlines.
• Attention to detail and analytical skills.
• Ability to work independently and as part of a team.
• Bilingual skills preferred.

Pay Range and Compensation Package

The pay range and compensation package for this role will be determined based on the candidate’s experience, skills, and other relevant factors.

Equal Opportunity Statement

Our client is an equal opportunity employer. They celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, or national origin.