Claims Representative II

This is a fully remote position.

About Our Client

This organization operates within the workers'' compensation insurance sector, addressing the complexities of claims management for injured employees and employers. It focuses on managing claims effectively across various jurisdictions by ensuring appropriate compensability determinations, reserve setting, and settlement negotiations. The company supports clients with claims of varying complexity, including large and labor-intensive cases, and emphasizes compliance with state legislation while controlling costs.

About the Opportunity

The Claim Representative II role involves managing moderately difficult workers'' compensation claims. The position requires exercising discretion in determining claim compensability and negotiating settlements within assigned authority. The role impacts the organization by ensuring accurate claim resolutions, supporting return-to-work efforts, and maintaining strong client relationships. This position also includes handling complex claims and mentoring less experienced team members.

Responsibilities

• Verify workers'' compensation coverage for employers and injured employees.
• Investigate claims to determine compensability.
• Assess causal relationships between injuries and incidents.
• Facilitate return-to-work processes for injured employees.
• Establish appropriate claim reserves within authority limits.
• Document claims with potential for subrogation recovery.
• Manage medical bills related to claims.
• Close claims following resolution and compliance with regulations.
• Negotiate settlements within authority.
• Collaborate with management on complex or high-value claims.
• Manage outside vendors to contain costs.
• Maintain effective relationships with internal and external customers.
• Stay informed on workers'' compensation laws, case law, and rehabilitation trends.
• Administer complex and catastrophic claims, including large accounts.
• Exercise independent judgment to settle claims before mediation or litigation.
• Participate actively in agent and client relationship management.
• Assist in mentoring team members.

Requirements

• Bachelor’s degree or equivalent combination of education and experience.
• Minimum of three years’ experience in workers'' compensation claims handling.
• Experience managing claims across multiple jurisdictions preferred.
• Bilingual skills preferred.
• Proficiency with computers and relevant software.
• Knowledge of medical and legal terminology related to workers'' compensation.
• Understanding of workers'' compensation laws and jurisdictional regulations.
• Strong oral and written communication abilities.
• Effective customer service and negotiation skills.
• Ability to manage multiple priorities and meet deadlines.
• Strong attention to detail and analytical capabilities.
• Ability to work independently and as part of a team.
• Ability to make independent decisions and solve complex problems.