Workers' Compensation Medical Only Claim Representative

Duties & Responsibilities

• Handles all aspects of workers’ compensation medical only claims from set-up to case closure, ensuring strong customer relations are maintained throughout the process.
• Reviews claim and policy information to provide background for the investigation.
• Conducts three-part ongoing investigations, obtaining facts and taking statements as necessary, with the insured, claimant, and medical providers.
• Evaluates the facts gathered through the investigation to determine the compensability of the medical treatment.
• Informs insureds and claimants of claim denials when applicable.
• Prepares reports on investigations, settlements, denials of claims, evaluations of involved parties, etc.
• Timely administration of statutory medical only benefits throughout the life of the claim.
• Sets reserves within authority limits for medical and expenses and recommends reserve changes to Team Leader throughout the life of the claim.
• Reviews the claim status at regular intervals and makes recommendations to Team Leader to discuss problems and remedial actions to resolve them.
• Prepares and submits to Team Leader unusual or possible undesirable exposures when encountered.
• Controls and directs vendors, nurse case managers, and telephonic case managers on medical management.
• Complies with customer service requests, including Special Claims Handling procedures and file status notes.
• Sets up and administers workers’ compensation forms and electronic data to states to ensure compliance with statutory regulations.
• Refers appropriate claims to subrogation and secures necessary information to ensure that recovery opportunities are maximized.
• Works with in-house Technical Assistants, Special Investigators, Nurse Consultants, Telephonic Case Managers and Team Supervisors to exceed customers' expectations for exceptional claim handling service.

Technical Skills & Competencies

• Knowledge of insurance, claims, and workers’ compensation statutes, regulations, and compliance is a plus, but on-the-job training will be provided to the chosen applicant.
• Ability to incorporate data analytics and modeling into daily activities to expedite the fair and equitable resolution of claims and claim issues.
• A personal commitment to superior performance that adds value to our company and our customers.
• Ability to work effectively with a wide variety of people.
• An aptitude for evaluating, analyzing, and interpreting information.
• Superior telephonic skills.
• Excellent organizational skills.
• The ability to multi-task with proven time management skills to meet deadlines.
• Ability to work well in teams.
• Demonstrate critical thinking and decision-making ability.
• Excellent verbal and written communication skills.

Experience, Education, & Requirements

• Experience working in a customer-focused, fast-paced, fluid environment.
• Prior experience requiring a high level of organization, follow-up and accountability.
• Prior workers’ compensation claim handling experience is a plus but not required.
• Familiarity with claim handling (healthcare, short-term / long-term disability, auto personal injury protection, medical injury, or general liability) is a plus but not required.
• Prior insurance, medical billing, legal or corporate business experience is a plus but not required.
• AIC, RMA, or CPCU-completed coursework or designation(s) is a plus but not required.
• Proficiency with Microsoft Office Products.
• Knowledge of medical terminology is a plus but not required.
• Knowledge of bill processing is a plus but not required.
• Claim adjuster licenses in Connecticut (all casualty lines), New Hampshire (workers’ compensation), Rhode Island (workers’ compensation), and Vermont (workers’ compensation) are required.
• If you do not already have one, you will be required to obtain an applicable resident or designated home state adjusters license and possibly additional state licensure.