Senior Claims Representative (Remote)

About the role

The organization operates within the insurance industry, focusing on workers' compensation claims. It addresses the challenges of managing complex, high-exposure claims involving legal intricacies and long life cycles. The company emphasizes integrity, collaboration, and innovation to support its policyholders and injured workers, aiming to deliver exceptional service while fostering a supportive environment for its employees.

The Senior Claims Representative role is central to managing high-exposure workers' compensation claims with a focus on thorough investigation, cost control, and compliance. This position significantly influences the organization’s strategic outcomes by leading fraud investigations, settlement negotiations, and cross-departmental collaborations. The role also supports team development through mentoring and process improvements, ensuring both regulatory adherence and exceptional service.

Responsibilities

• Manage highly complex workers’ compensation claims with significant financial exposure and extended life cycles.
• Conduct detailed investigations into coverage, compensability, and potential fraud.
• Oversee medical case management for catastrophic injuries and lifetime care.
• Review and authorize complex medical bills, negotiating adjustments to control costs.
• Develop return-to-work strategies in coordination with stakeholders.
• Ensure accurate benefit calculations addressing tax and compliance risks.
• Lead subrogation efforts and negotiate with third parties for recovery.
• Partner with legal teams to manage settlements, litigation, and Medicare compliance.
• Produce strategic reports to inform management decisions.
• Maintain data integrity and prepare claims for corporate review.
• Lead initiatives to improve claims handling and risk management.
• Resolve escalated customer service issues and support high-value accounts.
• Mentor junior and intermediate adjusters; provide feedback and support workforce development.

Requirements

• Bachelor’s degree in business or related field preferred, or equivalent experience.
• 7 to 10 years of experience handling workers’ compensation claims with high exposure.
• Preferred designations: Associate in Claims (AIC), AIM, or CPCU, or ability to obtain.
• Preferred Texas All-Lines license.
• Valid driver’s license.

Benefits

• Medical, dental, and vision insurance including fertility benefits, preventative care, and adult orthodontia.
• Employer-paid life and disability insurance (life insurance at 3x base salary, AD&D, short and long-term disability).
• Wellness and recognition programs with incentives.
• Flexible Spending Account and Dependent Care options.
• Health Savings Account with generous employer contribution.
• Generous paid time off including PTO, holidays, early releases, volunteer time, paid parental leave, and additional leave types.
• Employee assistance programs.
• 401(k) retirement plan with employer match and profit sharing.
• Adoption and tuition assistance.