WC Claim Representative II - CA experience required

About the role

This position encompasses three levels of workers' compensation claim handling: Claim Representative I (entry level), Claim Representative II (intermediate level), and Claim Representative III (advanced level). All levels involve investigating claims, determining compensability, establishing reserves, negotiating settlements, and managing medical bills. Higher levels handle more complex claims, exercise greater discretion, and take on mentoring and coordination responsibilities.

Responsibilities

All Levels (I, II, III):

• Verifies workers' compensation coverage of employers and injured employees
• Determines compensability under workers' compensation through thorough investigation
• Determines causal relationship between reported injury and incident to ensure appropriate benefit payment
• Facilitates return to work for injured employees
• Establishes timely and appropriate reserves based on claim profile within given authority
• Documents specifics of claims with potential for subrogation recovery, including amount of potential recovery monies
• Manages medical bills for non-indemnity and indemnity claims; approves payment based on treatment plan and medical support
• Concludes and closes files following resolution to meet performance standards while complying with state legislation
• Negotiates settlements with attorneys or injured parties within given authority
• Works closely with manager on complex files or files above settlement/reserve authority
• Manages outside vendors to ensure cost containment
• Establishes and maintains effective working relationships with internal and external customers
• Stays abreast of changes in workers' compensation statutes, case law, and rehabilitation efforts

Additional Responsibilities (II, III):

• 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

Additional Responsibilities (III):

• Mentors team members
• Conducts audits of claim files
• Acts as a back up for team leader
• Coordinates special projects

Qualifications

Education: Bachelor's degree in a related field. Relevant combination of education and experience may be considered in lieu of degree. Continuous learning is required. Certification or progress toward certification is highly preferred and encouraged.

Experience:

• Claim Representative I: Minimum one year relevant experience that provides necessary skills, knowledge and abilities, or completion of claims trainee program. Bilingual skills preferred.
• Claim Representative II: Three years experience in a workers' compensation claims environment that provides necessary skills, knowledge and abilities, such as experience in reviewing, investigating and closing workers' compensation claims. Experience handling claims in multiple jurisdictions preferred. Bilingual skills preferred. OR one year of AF Group Claims Representative I experience that includes handling of difficult or complex claims.
• Claim Representative III: Five years experience in a workers' compensation claims environment that provides necessary skills, knowledge and abilities, such as experience in reviewing, investigating and closing complex workers' compensation claims. Experience handling claims in multiple jurisdictions preferred. Bilingual skills preferred. OR two years of AF Group Claims Representative II experience that includes discretion in determining compensability of complex claims and/or handling complex, high touch or labor intensive customers.

Skills

All Levels (I, II, III):

• Ability and proficiency in the use of computers and company standard software
• Knowledge of medical and legal terminology related to the work
• Knowledge of workers' compensation laws and regulations, including jurisdictional laws
• Effective oral and written communication skills
• Effective customer service skills
• Ability to negotiate, build consensus and resolve conflict
• Ability to manage multiple priorities and meet established deadlines
• Attention to detail and analytical skills
• Ability to work independently as well as within a team

Additional Skills (II, III):

• Ability to make independent decisions
• Ability to solve complex problems

Additional Skills (III):

• Ability to train and mentor others

Working conditions

Work is performed in an office setting with no unusual hazards. Minimal travel required.