Senior Claims Representative

About the role

MEM Insurance is seeking a Senior Claims Representative to join our Claims team. This pivotal role involves managing high-exposure workers’ compensation claims, leading investigations into coverage and fraud, and collaborating across departments to drive strategic outcomes.

Responsibilities

• Manage highly complex claims involving significant financial exposure, legal intricacies, and extended life cycles.
• Conduct advanced investigations into coverage and compensability, including nuanced statutory interpretations.
• Oversee medical case management for catastrophic injuries and lifetime care needs.
• Review and authorize large or complex medical bills, negotiating adjustments to control costs.
• Return-to-Work Management: Develop comprehensive RTW strategies in collaboration with policyholders, legal counsel, and vocational consultants.
• Ensure precision in benefit calculations for high-exposure claims, addressing tax and compliance risks.
• Strategically deploy investigative efforts aligned with broader claims strategy.
• Claims Investigation & Loss Prevention: Lead investigations into complex fraud cases and collaborate with the Special Investigations Unit.
• Conduct subrogation analysis and negotiate with third-party insurers or attorneys for maximum recovery.
• Settlements & Negotiation: Partner with legal teams to negotiate complex settlements and manage litigation processes.
• Identify opportunities for structured settlements and lead negotiations.
• Reporting: Produce strategic reports on high-profile claims to guide management decisions.
• Maintain system data integrity and prepare claims for Corporate Plan of Action meetings.
• Collaboration: Lead cross-departmental efforts to improve claims handling and risk management.
• Resolve escalated customer service issues and support high-value accounts.
• Participate in workflow improvement initiatives and committees.
• Team Leadership: Mentor and coach junior and intermediate adjusters.
• Review escalated claims and provide actionable feedback.
• Support workforce development and succession planning.

Qualifications

• Bachelor’s degree in business or related field preferred, or equivalent industry experience.
• 7–10 years of claims handling experience, with high exposure to Workers’ Compensation.
• Associate in Claims (AIC), AIM, or CPCU designation preferred or ability to obtain.
• Texas All-Lines license preferred.
• Valid driver’s license required.