Claim Representative II

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Verifies workers’ compensation coverage of employers and injured employees.
• Determines compensability under workers’ compensation by thorough investigation of the claim.
• Determines causal relationship between the reported injury and the incident to ensure appropriate payment of benefits.
• Facilitates return to work for the injured employee.
• Establishes timely and appropriate reserves based on the profile of the claim within given authority based on anticipated financial exposure.
• Documents specifics of claims with potential for subrogation recovery, including amount of potential recovery monies.
• Manages medical bills for non-indemnity and indemnity claims directly associated with the claimed injury.
• Approves payment based on knowledge of the treatment plan and medical support showing relationship of treatment to the injury.
• Concludes and closes files following resolution of claims to meet internal performance standards while complying with state legislation to avoid penalties and manage expenses.
• Negotiates settlements with attorneys or injured parties within given authority at the earliest possible point to bring cases to final disposition.
• Works closely with manager on complex files or files above settlement/reserve authority.
• Manages outside vendors to ensure cost containment efforts.
• Establishes and maintains effective working relationships with all internal and external customers.
• Stays abreast of changes in workers’ compensation statutes, case law and rehabilitation efforts/advancements in order to accurately interpret and apply relevant laws.
• Administers complex claims and catastrophic exposures within authority, including claims from dedicated large accounts.
• Exercises independent judgment to settle cases prior to mediation or litigation.
• Actively participates in agent/client relationship management.
• Assists in mentoring team members.

Qualifications

• Relevant combination of education and experience may be considered in lieu of degree.
• Bachelor’s degree in a related field.
• Continuous learning, as defined by the Company’s learning philosophy, is required.
• Certification or progress toward certification is highly preferred and encouraged.
• Three (3) years of experience in a workers’ compensation claims environment which provides the necessary skills, knowledge and abilities, such as experience in reviewing, investigating and closing workers’ compensation claims.
• Experience of handling claims in multiple jurisdictions preferred.
• Bilingual skills preferred.
• OR One (1) year of AF Group Claims Representative I experience that includes handling of difficult or complex claims.