WC Claims Representative 1

Responsibilities

• Investigates workers’ compensation injury/illness claims, documents claim handling, and pays and/or denies benefits in a caseload of primarily medical only (MO) workers’ compensation claims.
• Limited indemnity (disability) claims may be assigned to representatives for training purposes, at supervisor discretion.
• This position is also responsible for providing support to the claims department.
• Investigate claims for compensability by analyzing claims-related information and applying claim handling guidelines.
• Verify active policy/coverage on new claims and determine if claim involves medical benefits only or includes exposure for lost time.
• Establish case reserves consistent with exposure on new claims. Examine reserves on a regular basis and adjust reserves if there is a significant change in exposure.
• Serve and file state forms when required.
• Investigate subrogation issues on claims, and place responsible third parties on notice of our client’s subrogation interest. Pursue subrogation or transfer file as appropriate.
• Receive and respond to telephone inquiries. This includes but is not limited to contact with injured employees, employers and health care providers.
• Authorize payment of bills for reasonable and necessary medical treatment, expenses associated with claims investigations and obtaining records.
• Send bills and records for audit when appropriate.
• Authorize or deny medical benefits within established time frames.
• Manage caseload with assistance of computer-operated diary and maintain current diaries.
• Participate in on-going training opportunities to remain current on all aspects of claims handling and customer service.
• Ensure timely filing of regulatory documents via EDI (Electronic Data Interchange); submit applicable claims to Index Bureau Reporting (ISO) and document files as applicable.
• Provide additional levels of management and claim department operational support to include payment review/approval/input and complete scheduled or special project work as needed.

Qualifications

• May perform other functions as assigned
• Minimum of two years office experience or post-high school education.
• Ability to interpret and evaluate limited medical and limited legal concepts.
• Analysis and decision-making skills.
• Good to excellent math and analytical ability.
• Good oral and written communication skills.
• Willing to learn and apply negotiation techniques.

Education

• High school diploma or equivalent

Additional Company Details

• The Company is an equal employment opportunity employer.
• We do not accept unsolicited resumes from third party recruiting agencies or firms.
• The company offers a competitive compensation plan and robust benefits package for full time regular employees including:
• Base Salary Range: $44k-$55k
• Benefits include Health, dental, vision, dental, life, disability, wellness, paid time off, 401(k) and profit-sharing plans

Additional Requirements

• Travel: Occasional Travel

Sponsorship Details

• Sponsorship not Offered for this Role