Claims Representative (Senior) - Workers Comp

Summary/Job Purpose:

This position is responsible to adjust assigned claims within delegated limits of authority, conduct timely and thorough investigations, handle subrogation claims, and complete fair and equitable claim settlements in accordance with company Claim Handling Guidelines and/or requirements of principals regarding TPA business to ensure services are provided in a fair, equitable and timely manner.

Essential Functions:

Claims Handling 60%

 

· Receives new claim assignments of a moderate to complex nature and analyzes the nature of the claim to determine required investigation and handling. Determines and identifies indemnity issues or questions of coverage in accordance with company Claims Handling Guidelines and/or requirements of principals regarding TPA business.

 

· Performs timely and thorough investigations including necessary survey arrangement in compliance with all jurisdictional requirements and/or entitlements.

 

· Conducts an informed case analysis to initiate reserve changes within assigned authority and makes recommendations to supervisor or manager where assigned authority is exceeded.

 

· Manages, controls and negotiates timely and equitable claim payments and settlements in accordance with jurisdictional and fair claims practice requirements and company policy and procedures. Investigates, evaluates and resolves moderate level claims files.

 

· Maintains current case diary and ensures retention of appropriate hard copy file documentation. Provides accurate claims system documentation as required by company claim manuals and procedures. Responsible for completion and/or submission of claim forms and reports as required by outside agencies.

 

· May handle subrogation of claims within delegated limits of authority, including identification of responsible parties, preparation of claim notice, correspondence with carriers, and negotiation of settlement in accordance with company Recovery Procedures.

 

· May be required to assign the defense of lawsuits to approved defense counsel; directs and monitors quality and performance of defense counsel. Maintains compliance with all requirements of the company’s Litigation Management Program. Reviews and adjusts, where appropriate, fee bills and legal expenses for accuracy and reasonableness.

Customer Service 30%

 

· Services the claim needs of our customers including insureds, claimants, brokers, etc., in accordance with company policy and procedures, and attends client visitations with underwriters and other parties to conduct presentations and reviews.

 

· Maintains ongoing communication with all customers throughout the claims process in an effort to provide timely and appropriate claim status as appropriate and/or required by statutory regulations.

 

Regulatory and Operational Compliance 10%

 

· Completes timely and accurate data reports to state reporting agencies to ensured full compliance with company and regulatory requirement.

 

· Maintains full compliance with all regulatory Fair Claim Practices Acts and state and federal regulations.

 

· Maintains full compliance with all state licensing and continuing education requirements to ensure current and appropriate filing/standing of all adjuster licenses.

Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and Experience Required:

Diploma/Degree & Experience

· High School Degree or G.E.D. is required. Bachelor's degree (B. A.) is preferred.

· 5+ years of claims experience, including ability to successfully negotiate settlements, verify coverage, appropriately set reserves, successfully complete investigations and understand rules associated with state regulations

 

Language Skills

· Ability to read, analyze, and interpret general business periodicals and business correspondence / instructions, and procedure manuals. Ability to effectively present information and respond to questions from managers, clients, customers, and the Representatives.

 

Mathematical Skills

· Ability to calculate figures and amounts such as wage rates, mileage allowance, sales tax, depreciation, discounts, interest, commissions, proportions and/or percentages.

 

Reasoning Ability

· Ability to solve practical problems. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

 

Computer Skills

· To perform this job successfully, an individual should have knowledge of Microsoft Word, Excel, and Outlook software. Knowledge of IVOS or other claim systems preferred.

Other Qualifications Required:

Certifications: Advanced Claim Technical Training preferred, Multi-state adjuster licenses required

Designations: Fraud Claim Specialist

Other Skills and Abilities Required:

May be required to work overtime to meet the needs of the business.

Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. The company provides reasonable accommodation to enable individuals with disabilities to perform the essential functions of the job in accordance with applicable law.

Regularly Frequently Occasionally, Sitting, Standing, Walking, Climbing/Balancing, Reaching with Arms/Hands, Stooping/Kneeling/Crouching/Crawling, Talking, Hearing

Vision – Close/Peripheral/Depth/Ability to Adjust Focus

Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The statements herein are intended to describe the general nature and expectations for this position, and are not to be an exhaustive list of required functions, skills and competencies. This job description does not establish a contract for employment and is subject to change at the sole discretion of the Company.